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AUTUMN 2004 



Ha.rva.Td Medical 



ALUMNI BULLETIN 




WHAT HAPPENS WHEN DOCTORS 
START TO FEEL FUNNY? 



Overcoming a childhood bout of 
polio, Tenley Albright '61 captured 
figure skating gold at the 1 956 
Winter Olympics, the first American 
woman to do so. Within a year of 
her triumph, Albright retired from the 
sport, turning down lucrative offers to 
skate professionally — and such dan- 
gled perks as a shiny white Cadillac. 
Instead Albright chose to enter HMS 
and, like her father, Hollis Albright '31 , 
pursue a career in surgery. She is 
pictured here as a second-year 
medical student en route to Europe 
on the Queen Elizabeth. 







CHAMPION 



AUTUMN I 4 • VOLUME 78, NUMBER 2 



CONTENTS 




DEPARTMENTS 



Letters 3 

Pulse 6 

A revivified Warren .Anatomical Museum, 
the State of the School, renewed resources 
for AIDS, the Class of 2008, and a fund 
honoring Alvin Poussaint's mentoring 
roleatHMS 

Bookmark 10 

A review by Elissa Ely of Them and lis. 
Cult Thinking and the Terrorist Threat 

Bookshelf 11 

Benchmarks 12 

Shared laughter may help build empathy 
in therapy sessions. 

Alumna Profile 52 

Yvette Roubideaux tackles diabetes 
among Native Americans, by Janice O'Leary 

Class Notes 54 

InMemoriam 59 

George W. Thorn 

Obituaries 60 

Faint of Heart 64 

What happens when a medical student 
who faints at the sight of blood under- 
takes her surgery rotation? by Elissa Ely 



SPECIAL REPORT: HUMOR IN MEDICINE 



Monkey Business 14 

When someone slips on a banana peel, why do we sometimes laugh — and 
sometimes call the doctor? by a l i c e flaherty 

Sick Humor 20 

Medical training can warp your sense of humor — and humor can help 
you make sense of your medical training. Ivpehri klass 

Dead Reckoning 24 

A young Jazz Age intern worries that some improvised words at a 
deathbed may well prove to be his last, dv albert h y m a n 

The Urge to Titter 28 

Keeping a straight face in the clinical encounter isn't always all it's cracked 

Up CO be. by WILLIAM IRA BENNETT 

The Etiology and Treatment of Childhood 32 

For decades now. physicians have turned a clinical eye on small fry. 
Why, then, does the epidemic persist? b jordan w. s m o l l e r 

Comic Relief 36 

Harvard Medical School alumni own up to clinical mishaps, slips of 
the lip, and other ludicrous moments in their professional lives. 



Banna 

True Grit 40 

From impeccable geniuses 
to scruffy con men, the 
Boston City Hospital of old 
housed a richly eccentric 
cast of characters whose 
lessons are not easily forgotten. 

i)V PIETER KARK 



Ties That Bind 48 

The reluctant decision to set aside his 
scalpel for good prompts a surgeon to 
reflect on decades of dedication to his art. 

by KEN KENIGSBERG 



Cover image: Christopher Harting; Mr. Potato 
Head® and ©2004 Hasbro, Inc. Used with 
permission. 




Har va rd M edical 



ALUMNI BULLETIN 




In This Issue 

OR YEARS I'D BEEN PESTERING ALUMNI TO TELL ME FUNNY MEDICAL STORIES. 

"One comes to mind immediately!" a physician of international 
renown exclaimed, his eyes lighting up. "I was an intern at the 
House of the Good Samaritan, where we treated children with 
rheumatic fever. A distinguished professor in a bowtie was leaning over a toddler's 
bed when the little boy suddenly sat up and spat in the doctor's face." 

I nodded encouragingly, awaiting the punchline. 

"Of course," the physician said, looking off into the distance, "the child 
did die two weeks later." He paused, and his voice grew faint. "Well, we all 
thought it was hilarious at the time." 

Suddenly I understood why our special report on humor in medicine was 
taking so long to produce: not only are physicians' memorable stories too 
often tinged with tragedy, but what seems comic in the moment can prove 
maddeningly elusive in the retelling. Other clues began accruing: a psychia- 
trist drafting a humor essay kept finding his jokes dying on the page. "Eek, 
I've let you down!" bemoaned an internist. "When I wrote out my experi- 
ences, they didn't seem funny after all." Clearly the Bulletin was being seized 
by a you-had-to-have-been-there paralysis of wit. 

Perri Klass '86 had warned me that medical training can warp one's sense 
of humor. But I knew doctors could be funny. Even so, after more than a year of 
granting requests for deadline extensions for our humor issue, I despaired of 
being able to feature alumni voices in the Bulletin's pages. And I found myself 
tempted by The New Yorker cartoons available for reprinting ("So, could we have 
all your stuff after you die?" a physician asks his patient in a panel titled "Doctors 
Without Boundaries") and the bloopers found in doctors' dictations, as captured 
in The Bride of Anguished English ("The baby was delivered, the cord clamped and 
cut and handed to the pediatrician, who breathed and cried immediately"). 

But a final shard of understanding kept us from giving up on our alumni. We 
had considered approaching Conan O'Brien, best known in Harvard Medical 
School circles as the son of microbiology professor Thomas O'Brien '54. Would 
the father mind our asking the son to write something witty for us? "Not 
at all," the good doctor replied, "only I doubt he'll have the time; it's tough 
coming up with enough material for his show." 

If the humor professionals were struggling, then we could certainly grant 
our alumni more time. And the stories finally came trickling in: medical 
students fainting at the sight of blood, young Harvard men dashing home 
in quickly disintegrating seersucker suits, patients lifting up their shirts 
to reveal abominable abdominal art. At last we needn't have been there to 
recognize humor in those stories. 



EDITOR-IN-CHIEF 

William Ira Bennett '68 

EDITOR 

Paula Brewer Byron 

ASSOCIATE EDITOR 

Beverly Ballaro, PhD 

ASSISTANT EDITOR 

Janice O'Leary 

BOOK REVIEW EDITOR 

Elissa Ely '88 



EDITORIAL BOARD 

Judy Ann Bigby 78 
Rafael Campo '92 

Elissa Ely '88 

Alice Flaherty "94 

Atul Gawande '94 

Robert M. Goldwyn '56 

Perri Klass '86 

Victoria McEvoy 75 

James J. O'Connell '82 

Nancy E. Oriol 79 

Mitchell T. Rabkin '55 

Eleanor Shore '55 



DESIGN DIRECTOR 

Laura McFadden 



ASSOCIATION OFFICERS 

Joseph K. Hurd. Jr. '64, president 

Steven A. Schroeder '64. president elect 1 

A. W. Karchmer '64, president elect 2 

Susan M. Okie 78, \ice president 

Phyllis I. Gardner 76, secretary 
Kathleen E. Toomey 78, treasurer 



COUNCILLORS 

Nancy C. Andrews '87 
Wesley A. Curry 76 
Timothy G. Ferris '92 
Gerald S. Foster '51 
Donnella S. Green '99 
Linda S. Hotchkiss 78 

Lisa I. Iezzoni '84 

Katherine A. Keeley '94 

Kenneth I. Shine '61 



DIRECTOR OF ALUMNI RELATIONS 

Daniel D. Federman '53 

ASSOCIATE DEAN FOR ALUMNI 
PROGRAMS AND SPECIAL PROJECTS 

Nora N. Nercessian, PhD 

REPRESENTATIVES TO THE 
HARVARD ALUMNI ASSOCIATION 

Harold Bursztajn 76 
Joseph K. Hurd, Jr. '64 

The Harvard Medical Alumni Bulletin is 

published quarterly at 25 Shattuck Street. 

Boston. MA 02115 r by the Harvard 

Medical Alumni Association. 

Phone: (617) 384 8900 • Fax: (617) 384-8901 

Email: bulletin@hms.harvard.edu 

Third class postage paid at Boston. 

Massachusetts. Postmaster, send form 3579 

to 25 Shattuck Street, Boston, MA 02115 

ISSN 0191-7757 • Printed in the U.S.A. 






HARVARD MEDICA1 ALUMNI BULLETIN • AUTUMN 2004 




H .'' 



SECOND OPINIONS FROM OUR READERS 



IF.TTF.RS B* 



Table Manners 

I was especially interested in the con- 
tents of the Spring 2004 edition, as 
it stirred up so many memories. For 
starters, I took the Course in Aseptic- 
Technique, also known as dog surgery, 
supervised by Carl Walter '32. I had 
enjoyed the definitive nature of surgical 
decisions and was strongly consider- 
ing a surgical career. But that course 
changed my plans. One factor was that 
my mind seemed more agile than my 
hands; another was that it was rumored 
that Dr. Walter would kick your hand if 
it strayed below the plane of the operat 
ing table, then he'd make you rescrub. I 
figured if that happened Co me, I might 
be tempted to grab his foot and toss him 
on his rear. I somehow sensed that such 
a response might end my career, so I 
dropped the idea of pursuing surgery. 

The second story that evoked strong 
emotion in me was the anecdote Samuel 
Potsubay '40 told about noticing a thy 
roid disorder in a triend's wife. I was 
a medical intern at the Peter Bent 
Brigham Hospital, where we ate with 
the nurses in the evenings. I was gazing 
at a lovely student nurse from Children's 
Hospital when I noticed a prominence 
of her thyroid. In my best professional 
manner, I asked her it I could palpate it. 
She blushed prettily, and agreed. That 
same woman, Ellie, and I recently cele- 
brated our 50th wedding anniversary! I 
believe that was the first and last time 
that ploy was used. (Incidentally, she 
did have a goiter that resolved on thy 
roid supplement.) 

Thanks for the memories. 

WARREN GUNTHEROTH '52 
SEATTLE, WASHINGTON 



Joint Returns 

I was sad to read of the demise of the 
Harvard Surgical Research Laboratory 
in your recent article "Joint Ventures." I 
underwent the Carl Walter '32 scrutiny 
there as a medical student, returned to 
help teach that course in surgical tech- 





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The pedestrian's fractured tibia was sticking out 
through his torn trousers and being pulled through 
the mud. "Here, stop that, put him down!" Cutler cried 
to the driver who was dragging the pedestrian. But 
the man only snarled, "Quiet, you fool, I'm a doctor!" 



nique for a brief time, then had the 
opportunity to clone the course at 
UCLA. Graduates of UCLA from 50 
years ago still remind me of the lamp 
black and oil routine! 

In "The Case of the Canine Caper and 
Other Tales," by Samuel Potsubay '40, 
the story Elliott Cutler '13 told about 
Harvey Cushing's terrier brought back 
memories of other Cutler narratives. We 
were in medical school during the 
beginning of World War II, and civil 
defense and the care of civilian casual- 
ties were hot topics. To spice up those 
subjects Cutler told us two stories along 
the lines of "splint 'em where they lie." 

In one, he had been driving to the 
Peter Bent Brigham Hospital on a snowy 



day when he saw the car ahead of him 
go into a skid and pick off an unlucky 
pedestrian. Cutler stopped and rushed 
over in time to see the driver grab the 
pedestrian under the arms and start 
dragging him toward his car. Cutler 
could see the pedestrian's fractured tibia 
sticking out through his torn trousers 
and being pulled through the mud. 
"Here, stop that, put him down!" Cutler 
cried. But the driver of the other car only 
snarled, "Quiet, you fool, I'm a doctor!" 

The second Cutler story — more like- 
ly a fabrication — concerned two motor- 
cyclists who had been headed out on the 
Jamaica Way in Boston on a cold and 
windy fall day. Their jackets were catch- 
ing the cold air gusts, so they stopped to 



AUTUMN 2004 • HARVARD MEDICAL ALUMNI BULLETIN 



TETTERS 



SECOND OPINIONS FROM OUR READERS 





LEGENDS OF THE SPRING 

The Spring 2004 issue of the Bulletin was 
outstanding, from the Navajo articles to all of 
the stories about Drs. Cutler and Cushing, who 
gave our class memorable lectures and had us 
standing shoulder-to-shoulder with Edward 
Churchill, Class of 1920, as second and third 
assistants. This edition was easily on par with 
your 75th anniversary issue. 

DONALD BICKLEY '34 
WATERLOO, IOWA 



put their jackets on backward. As they 
pulled back into traffic, a truck hit 
them. The police officer reporting the 
incident wrote: "One of them was dead 
when I got there, and by the time I got 
the other's head turned around the right 
way, he was dead, too." 

I was in the last group of Brigham 
interns that Cutler chose, and, I believe, 
the last Cabot Fellow he appointed. My 
year in the lab was shared with future 
stars — Felix Eastcott of London, known 
later for one of the earliest carotid artery 
reconstructions, and Eric Rogers of 
Canada. David Hume was then deep 
into the study of the hypothalamus of 
hibernating animals, and there was the 
wonderful Charlie Hufnagel '41 of the 
first aortic valve. Hufnagel was surely 
one of the most dexterous and innova- 
tive surgeons I have ever met; sadly he 
was so modest he let many of his inno- 
vations pass into the surgical armamen- 
tarium without getting his name associ- 
ated with them. 

And, of course, hovering over us all 
was Carl Walter. I don't believe I ever 
did an operation later on without using 
something Carl taught me about surgi 
cal technique, nor did I ever watch 
another surgeon without thinking, "You 
could do it more easily if you followed 
Carl's techniques!" I never uttered those 
words out loud, however. 



My year in the laboratory came under 
the tenure of Francis Moore '39, who 
had succeeded Cutler while I had been 
in the Navy. That year was dedicated to 
the pancreas, especially studies of the 
accumulation of fat in the liver when 
the animal was deprived of some factor 
in the pancreas. 

What did stand me in good stead a 
few years later were the exercises Charlie 
Hufnagel urged on me, repeating as many 
of Alexis Carrel's vascular surgical proce- 
dures as I could fit into the schedule. 

WILEY F. BARKER '44 
AGOURA, CALIFORNIA 

Contractual Difficulties 

I found the article "Joint Ventures" in 
the spring issue of the Bulletin fascinat- 
ing. It brought back my fondest days at 
the Medical School. 

As part of my training, Elliott Cuder '13 
appointed me to the Arthur Tracy Cabot 
Fellowship and I spent more than a year 
in the Surgical Research Laboratory. 
One of my projects involved a study of 
peristalsis. In 1945, when I had been 
chief surgical resident for one year, 
William Ladd invited me to join the 
Children's Hospital staff. 

I spent a good deal of my time in the 
outpatient clinic and became interested 
in several desperately ill children with 



Hirschsprung's disease. I consulted 
Dr. Ladd and learned that he had tried 
all available treatments in vain. The 
patients were barely kept alive with fre- 
quent washout. 

One morning on rounds I was sur- 
prised to find the massive distention in 
one of these patients, who during the 
night had received a sigmoid colostomy, 
beginning to recede. By the next day his 
abdomen was concave, as if a mechani- 
cal obstruction had been relieved. But 
this was impossible, for an earlier sig- 
moidoscopic examination had revealed 
no obstruction. I immediately deter- 
mined to test the colon proximal to the 
colostomy for peristalsis and was 
stunned to record normal function. It is, 
after all, the absence of peristalsis that 
prevents the intestinal system from 
functioning in patients with this curi- 
ous, fatal disease. 

When I recorded distal to the 
colostomy I discovered that there was 
no peristalsis. Thus, the area of colon 
that appeared to be diseased was not; 
the problem lay not in the dilated seg- 
ment of colon but in the seemingly nor- 
mal area of the sigmoid and rectum. The 
last study of our results in treating this 
fatal disease by removing the entire 
obstructive lesion is composed of 880 
patients followed for up to 40 years, 
and 96 percent are healthy with normal 
intestinal function. 

ORVAR SWENSON '37 
CHARLESTON, SOUTH CAROLINA 



Unconventional Wisdom 

I wanted to comment on the quality of 
the Spring 2004 issue of the Bulletin. 
My wife and I were both struck by the 
number of very interesting articles and 
the attractive layout. I was particularly 
drawn to the report on G. Robert 
DeLong's work on iodine deficiency 
and cretinism, which I had not realized 
to be such an international problem 
still. Long ago, I knew Bob at Massa- 
chusetts General Hospital, where he 
was the first to teach me about bipolar 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 



disorder in children and one of the first 
to use lithium for its treatment in chil- 
dren. Many years later, I have come 
to understand the importance of that 
work and the continuing reluctance of 
many child psychiatrists to accept the 
proposition that even prepubertal chil 
dren can experience something like 
mania and major depression. 

ROSS BALDESSARINI, DSC, MD 
BELMONT, MASSACHUSETTS 



Dynamic Dynasty 

I thought my fellow alumni would be 
interested in knowing that when Michael 
Frank '60 stepped down from the 
chairmanship of the Department of 
Pediatrics at Duke University in March 
2004, we ended 50 consecutive years of 
successful leadership of our department 
by alumni of HMS. Jerome Harris '33 
served as chairman from 1954 to 1969, 
Samuel Katz '52 from 1969 to 1990, and 
Mike from 1990 to 2004. Each chairman 
more than met the particular challenges 
of his times, and together they helped to 
make our department one of the finest 
in the country. 

In his "retirement," Mike is following 
in the tradition of his predecessors by 
entering another productive phase of his 
career, in his case by returning to his 
laboratory to study complement. Sam 
is an important advocate for rational 
immunization policies in the United 
States and abroad, and Jerry served as 
chairman of the Institutional Review 
Board for many years after stepping 
down as department chairman. It has 
been my privilege to work with these 
fine colleagues for the past 25 years. 

GORDON WORLEY '73 
DURHAM, NORTH CAROLINA 



The Bulletin welcomes letters to the editor. 
Please send letters by mail (Harvard Medical 
.Alumni Bulletin, 25 Shattuck Street, Boston, 
Massachusetts 02115): fax (617'384-8901); or 
email (bulletin@hms.hanard.edu). Letters may 
be edited for length or clarity. 




SHARING THE MINERAL WEALTH 

OON AFTER THE SPRING 2004 ISSUE OF THE BULLETIN APPEARED, 

G. Robert DeLong '61 received an email from Tim Wallace, 
a Peace Corps worker in Kokand, Uzbekistan. Wallace had 
read the Bulletin's cover story which featured DeLong's efforts 
to find innovative ways to introduce iodine to regions that have been both 
tragically deficient in the precious mineral and resistant to conventional 
delivery methods. 

"I work with a local association of endocrinologists who are trying to 
reduce the level of endocrine diseases here," Wallace wrote. "Because of 
iodine deficiency the rate of goiter is approximately 80 percent for the area 
and as high as 99 percent in some rural areas. The organization worked on 
a project to fortify bread with iodine, but it wasn't sustainable. Another 
organization tried promoting iodized salt several years ago, but that also 
failed. I was hoping you might be able to provide us with some guidance." 
Two months later, DeLong visited Uzbekistan, where he met with Wallace 
and more than 80 physicians and other health care workers. They have 
since developed a proposal and hope to start, in the spring of 2005, a pilot 
project of dripping iodine into irrigation water in the Ferghana Valley, in 
an area with a population of 12,000. "One never knows the reach of one's 
work," DeLong says. "Many thanks to the Bulletin." 




AUTUMN 2004 • HARVARD MEDICAL ALUMNI BULLETIN 




PTIT.SK 



MAKING THE ROUNDS AT HMS 




HEAD OF THE CLASS: This rare 
nineteenth-century Beauchene 
or "exploded" skull of real bone 
was constructed for anatomical 
studies; today such teaching 
tools are made of plastic. 




Body of Knowledge 



HERE WAS NO COUGHING UP THIS 

hairball; removed from the 
stomach of a 50-year-old 
woman, it approximates a 
football in size, shape, and color. The 
patient had been employed at a wig fac- 
tory, and her doctor hypothesized that 
over the years she had inhaled the hair. 
Donated in 1933, the hairball is one of 
thousands of items belonging to the 
Warren Anatomical Museum, which 
helped generations of Harvard medical 
students learn their art. 

The hairball now forms part of a col- 
lection of specimens assembled by War- 
ren Museum archivists at the request of 
Kitt Shaffer, an associate professor of 
radiology at HMS, for her Human Body 
class. In addition to the hairball, the 
Human Body exhibit includes a prepara- 
tion of tattooed skin that illustrates two 
American flags flanking a memorial 
stone; golfball-sized bladder calculi; a 
portion of an articulated skeleton; and 
a nineteenth-century preparation show- 



ing an arm complete with arteries, veins, 
and nerves. To prepare this last speci- 
men, some skin was removed from the 
arm so that the arteries and veins could 
be injected with hot wax. When the 
wax dried, the tissue was cut away, cre- 
ating a wax model of the arteries and 
veins before the whole specimen was 
dried and then covered with a material 
similar to varnish. 

The exhibit also contains a pehis with 
a right femur and dislocated left femur 
attached, a specimen commonly referred 
to as the "Lowell hip." A prominent New 
Englander who had dislocated his hip in 
a fall from a horse, Lowell was dissatis- 
fied with the final result after treatment. 
Although he had not heeded his doctor's 
advice, he sued. His specimen later 
became associated with one of the earli- 
est medical malpractice cases to go to 
court. The court eventually ruled in favor 
of Lowell's doctors. When Lowell died, 
the Warren Museum's founder, John 
Collins Warren, who had served as a wit- 



The State of the Schoo 



IN HIS SEVENTH ANNUAL STATE OF THE SCHOOL ADDRESS, HMS DEAN 

Joseph Martin used a quotation from Ralph Waldo Emerson to 
define the institution's progress over the past year: "Do not go 
where the path may lead. Go instead where there is no path 
and leave a trail." 

Among the trailblazing efforts that have taken place at the 
School during the past year, Martin highlighted the AIDS activi- 
ties conducted by the faculty. "If one looks at the work that we 
are doing around the world, there is probably no focus more 
important than that involving AIDS," he said. Martin highlight- 
ed the Vietnam-CDC-Harvard AIDS Partnership, developed 
and directed by Eric Krakauer, an HMS instructor in social 
medicine. In just a few years, the program has trained more 
than 300 Vietnamese doctors. Martin also cited Harvard Med- 



ical International, which sup- 
ports AIDS education pro- 
grams in India, China, and 
other countries. 

"It has been truly remark- 
able how many things have 
happened just in the last 12 
months," Martin said, referring 
to the HMS research enter- 
prise. He pointed to the expansion of investigations in the New 
Research Building on the North Quad, which has freed up lab- 
oratory space on the South Quad. And he commented on sev- 
eral faculty collaborations, including one in which a combina- 
tion of clinically trained and basic science trained people are 




HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 



ness in the case, autopsied the body and 
donated the pelvis to the museum. 

Perhaps one of the most mysterious 
specimens on display is a collection of 
skeletal remains sent to the Warren 
Museum in 2000 by the coroner's office 
of Los Angeles County. Two wooden 
boxes were recovered from a dumpster 
in East Los Angeles. Within one of the 
boxes was a card indicating that the 
contents belonged to HMS. 

According to the anthropologist's 
report that accompanied the boxes, the 
contents included a cranium and various 
other human bones. All of the bones 
were bleached, and the top of the skull 
had been removed by a high-speed saw 
and then reattached with brass fittings. 
The report concluded that the remains 
had no forensic value and had likely been 
intended for educational purposes. 

So how did they find their way into 
an East Los Angeles dumpster? The 
inventory card in one box stated not 
only that the contents were the proper- 



ty of HMS, but that the student borrow- 
ing the box must return it when it was 
called for and would be charged for any 
loss or breakage. Remarkably, according 
to the inventory, the contents of both 
boxes were intact and in good condi- 
tion — quite impressive considering the 
last sign-out date on the card was 1952. 
During the nineteenth and early 
twentieth centuries, the Warren Muse- 
um became one of the country's leading 
medical museums. The collection began 
in 1800 with a gift from John Collins 
Warren, the first to hold the title of dean 
of HMS. Not only did Warren donate 
the anatomical specimens he had been 
collecting for years, but he later 
bequeathed his own skeleton to the 
museum. Later contributors included 
two of his descendants — Jonathan 
Mason Warren, Class of 1832, and John 
Collins Warren, Class of 1866 — and two 
subsequent deans of HMS — Oliver 
Wendell Holmes, Class of 1836, and 
J. B. S.Jackson, the museum's first curator. 




CSI: LOS ANGELES: The brass fittings used 
to reattach the top of a skull convinced 
the Los Angeles coroner's office that two 
boxes of bones found in a dumpster were 
of an academic rather than criminal origin. 



And now, some 20 years after the col- 
lection was last officially used for peda- 
gogical purposes, HMS students are 
once again enjoying the learning oppor- 
tunities that it offers. The exhibit gallery 
for the museum is located on the fifth 
floor of the Countway Library; visit 
www.countway.harvard.edu/warren/ 
index.shtml to learn more. ■ 



using a proteomic approach to look at the cellular events that 
lead to neurodegenerative disorders. 

Addressing the planning process for the new Allston cam- 
pus, Martin said, "One of the most important issues we will 
be facing this academic year is exactly how the Medical 
School will be engaging in this set of activities without in any 
way diminishing our strength here by the relocation of pro- 
grams or activities that would distance us from our students 
or from our hospitals." 

Changes in educational programs, said Martin, were also 
one of the year's major efforts. Martin acknowledged four new 
leaders of graduate programs, Robert Kingston, David Knipe, 
Gary Yellen, and Christopher A. Walsh. He also discussed 
reorganizing the Program in Medical Education, with Nancy 



Oriol '79 filling the new position of dean for students and 
Ronald Arky taking the new role of dean for curriculum. 

Martin outlined some of the progress of the Medical Educa- 
tion Reform Initiative. He identified the five central challenges 
as the content of the curriculum, student costs, compassionate 
and culturally competent care, the compensation of clinical 
teachers, and the chaos of academic health centers. Despite 
these hurdles, the initiative is on track to roll out the new cur- 
riculum in the fall of 2006. 

Likewise, Martin said, budgetary challenges face the 
School in building on the accomplishments of the past year, 
but the administration is optimistic about eliminating the 
remaining deficit and continuing on its present course of 
growth and discovery. ■ 



AUTUMN 2004 • HARVARD MEDICAL ALUMNI BULLETIN 




JlL I J I a i) J-j 



MAKING THE ROUNDS AT HMS 



Banding Together Against AIDS 




OST OF THE ESTIMATED 14,000 

people a day worldwide who 
become infected with HIV live 
in nations desperately short 
on resources. A number of Harvard 
Medical School researchers have there- 
fore been striving to provide leadership 
in the struggle against AIDS not only in 
the United States, but in the developing 
world as well. 

And now the National Institutes of 
Health has announced that it will fund 
a new HMS Center for AIDS Research 
(CFAR) with a total of $15 million over 
five years. The award, which reflects an 
integration of two existing HMS based 
CFARs, doubles the CFAR funding cap 
of $1.5 million per year. 

As principal investigators of the two 
previous CFAR awards, Bruce Walker, 
head of the HMS Division of AIDS, 
and Joseph Sodroski, HMS professor of 
pathology at the Dana-Farber Cancer 
Institute, petitioned the National Insti- 
tutes of Health to raise the cap and make 
the integration fiscally viable. 

"We are excited about this award," 
Walker says, "and we see the CFAR as 




GRIM LEGACY: A South African woman 
sits surrounded by the grandchildren 
she adopted after their parents died of 
AIDS. The children are clutching their 
parents' death certificates. 




a forum where people can come togeth- standing components that are already 

er under a common umbrella to get here at Harvard." 

things done and to try to realize the "This expanded program is a case," 

most synergy possible from the out- Sodroski adds, "in which the new whole 



The Class of 2008 



THE NEWEST MEMBERS OF THE HARVARD MEDICAL SCHOOL COMMUNITY — THE CLASS OF 

2008 — donned their ceremonial white coats in September. The class is 47 percent 
women and 53 percent men. Twenty-six percent of the students are Asian Americans, 
8 percent African Americans, 7 percent Latinos, and 3 percent Native Americans. 
The class represents 33 states, plus Puerto Rico, and 5 foreign countries: Bulgaria, 
Canada, India, Sweden, and Yugoslavia. 

The youngest entering medical student is 21 years old, the oldest is 29, and the 
median age is 23. Roughly three-fourths of the class majored in the sciences while 
undergraduates; 14 percent majored in the sociai sciences, 5 percent in the humani- 
ties, and 9 percent in other majors and/or double majors. ■ 

TAKING IT TO THE STREETS: A pre-orientation program, the First-year Urban 
Neighborhood Campaign, took place in August, introducing 55 members of 
the Class of 2008 to outreach opportunities in the Boston area. 



8 HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 



will be even better than the sum of 
already excellent parts." 

The NIH CFAR program provides 
administrative and research support to 
leading AIDS research projects. Twenty 
centers operate around the country, 
but Harvard's is the first new center to 
qualify for increased funding. The 
Harvard CFAR will revolve around five 
scientific programs: international, ther- 
apeutics, vaccine development, patho 
genesis, and epidemiology. The grant 
also allows support for feasibility stud 
ies, up to 550,000 per year for up to ten 
projects. "This will provide the neces- 
sary infrastructure and funding to 
explore high risk, high-impact research 
avenues," Sodroski says. 

The announcement of the new grant 
comes soon after the formation of the 
Harvard University Program on AIDS 
(HUPA), which will coordinate AIDS 
related programs throughout the Uni- 
versity under the umbrella of the Har- 
vard Initiative on Global Health, headed 
by Paul Farmer '90. "We see the CFAR as 
a founding program within HUPA that 
has the potential to bring schools and 
faculty together around AIDS-related 
research, whether that's in social sci 
ences, the political arena, legal areas, or 
any issue that supports the University's 
efforts to help end the AIDS pandemic," 
says Tom La Salvia, executive director of 
the HMS Division of AIDS. 

CFAR projects are already having an 
impact in some regions of the world that 
are hardest hit and least able to cope 
with AIDS, including the KwaZulu- 
Natal province in South Africa, the East- 
ern Caribbean, and Vietnam. 

"Bringing together the efforts of the 
two CFARs within the Harvard Medical 
community while embracing comple 
mentary efforts across Harvard creates 
powerful synergies to hasten our efforts 
to quell the global AIDS crisis," says 
Joseph Martin, dean of the Medical 
School. "This is a noteworthy example of 
the power of combining resources and 
research endeavors to unite disparate fac- 
ulty around HMS research priorities." ■ 




Saluting a Mentor 



A NEW FUND HAS BEEN CREATED TO HONOR A FACULTY MEMBER WHO HAS SERVED 

as a beloved mentor to hundreds of HMS graduates over the past 35 years: 
Alvin Poussaint, faculty associate dean for student affairs at HMS since 1969, 
is an expert on race relations in America, the dynamics of prejudice, and 
issues of diversity. Poussaint is also director of the media center at the Judge 
Baker Children's Center and a professor of psychiatry at HMS. 

From 1965 to 1967, Poussaint was southern field director of the Medical 
Committee for Human Rights in Jackson, Mississippi, providing medical care to 
civil rights workers and aiding in the desegregation of health facilities through- 
out the South. Two years later, HMS recruited him to its faculty 
in part to help shepherd the School's affirmative action efforts. 

When he joined the Harvard Medical School faculty, 
Poussaint became passionately committed to supporting 
diversity in the HMS community. It is a goal he has pursued in 
a variety of administrative roles at the School over the years. 

"Harvard Medical School students today not only interact 
with people from every socioethnic and cultural back- 
ground — especially from backgrounds less represented in 
medicine historically — but also learn a lot from the unique life 
experiences that their fellow students bring to the School," 
says Poussaint. "Diversity and diverse collaborations can pro- 
vide enormous benefits for the way that medicine is practiced 
in the United States and around the world." 

"Alvin Poussaint has been a mentor to thousands of students, residents, 
fellows, and junior faculty, as well as a trusted peer advisor to senior faculty 
at Harvard Medical School and across the country for nearly four decades," 
says Joan Reede, dean for diversity and community partnership at HMS. "It 
has been my honor and privilege to work closely with this remarkable man, 
who has had such a profound impact on medicine, psychiatry, and the 
image of the African American family in the media." 

The Alvin F. Poussaint, MD Visiting Lecture Fund at HMS will bring an under- 
represented graduate of the School or its affiliated training programs back to 
campus each year to give a lecture. The inaugural lecture and a celebration of 
the new fund will take place at HMS on February 1 2, 2005. ■ 



To learn more 

about the inaugural 

lecture and 

celebration, visit 

www.mfdp.med. 

harvard.edu/ 

celebratepoussaint 

or call 

617-432-1133. 



AUTUMN 2004 • HARVARD MEDICAL ALUMNI BULLETIN 



BOOKMARK 



REVIEWING THE PRINTED WORD 



Them and Us 



Cult Thinking and the Terrorist Threat 

by Arthur J. Deikman '55 (Bax Tree Publishing, 



>003) 




EARS AGO, I HAD A FRIEND WHO BELONGED TO A CULT. 

I got to know him before he joined. Eventually, I 
did not know him anymore. An exotic, fascinating 
serpent had swallowed him whole. I gazed from a 
safe distance, as through a telescope aimed at some evil galaxy. 

Cults are places for the fragile and misled. The strong- 
minded among us know better than to travel there ourselves. 
Therefore, it would seem implausible, as psychiatrist Arthur 
Deikman '55 argues in Them and Us, that "cult...thinking (is) so 
pervasive in normal society that almost all of us might be seen 
as members of invisible cults." The very suggestion threatens 
proud free will. 

But Deikman builds his case inexorably. Politics, religion, edu- 
cation, earnest professional identity, and ordinary social lives are 
all avenues of cult indoctrination. No 
one is immune. By the end of his book, 
you feel the wall against your back. 

Here is some of what the author 
says: we are indoctrinated without 
consciousness or intent, driven, as 
Freud once said, by unknown forces. 
It begins at birth. The most powerful 
force acts first in childhood, where 
parents offer absolute security in 
exchange for absolute dependency. 
We never lose the yearning to look 
to someone who can guarantee safe 
passage through ever-more treach- 
erous waters. 

Traditional cults manipulate this 
"dependency dream" in four ways: 
creating a leader (who is paternal at 

first, then autocratic); demanding compliance with the group 
(given willingly, then in fear); attacking dissent (which is 
framed in terms of disloyalty); and devaluing outsiders (who 
quickly become enemies). These were the tactics in Waco and 
in Guyana and among Tokyo's Aum Shinrikyo. Some see them 
in today's Islamic extremism, others see them operating behind 
the Religious Right. As tactics, they are not hard to spot — 
except when applied to ourselves. 

For instance, adherence to a cult leader who suppresses 
autonomy and demands "obedience and power...over truth and 
conscience" seems safely inconceivable to a thinking person. 
But what about CEOs who "inspire rather than overpower"? 
The religious leader guided by God who "brands disagree- 
ment.. .as a sign that the defiant member is lost to salvation"? 
The undoubting political leader who creates a "fantasy of 




invulnerability" and cites higher principles (including national 
security) to justify his actions? 

Cults allow no alternative \iews; they "inhibit and stifle dis 
agreement." Of course. But so do corporations, where survival 
of the business is a religious mission. Deikman describes the 
disastrous Corvair car, whose design caused it to flip at high 
speeds. General Motors engineers knew this, but their protests 
were overruled, catastrophically, by managers. 

In medicine, Ignaz Semmelweis, the physician who first 
warned that high rates of maternal deaths during delivery were 
caused by obstetricians with unwashed hands, was ridiculed so 
relentlessly by his peers that he went mad. Politics uses a differ- 
ent, coarser tactic to stifle disagreement: secrecy. Deikman argues 
that the AUende overthrow in Chile and the Iran- Contra scandal, 
among others, were engineered covertly to avoid criticism. 

But the most ubiquitous everyday cult behavior we practice is 
devaluing outsiders. Personal identity and moral value increase 
in direct proportion to the lesser worth of others. This tendency, 
Deikman writes, "provides a rationale for actions that would 

otherwise place us in the bad cat- 
egory." AIDS research, for exam- 
ple, was awarded less initial 
money than Legionnaire's dis- 
ease — which killed 29 people — 
because AIDS was seen as the 
disease of the sexual outsider. The 
examples in Them and Us multiply 
miserably and undeniably. This is 
grim, but not necessarily final. 

Deikman has a recommenda- 
tion: bring unconscious drives 
into consciousness; begin "the 



THE MADDING CROWD: Members of the Aum Shinrikyo 
cult— responsible for the deadly release of sarin in the 
Tokyo subway system in 1 995 — hold a demonstration 
clad in masks fashioned in the likeness of their leader. 



uncomfortable process" of foster- 
ing dissent. Dissent and discus 
sion, he contends, may be the 
only legitimate means to "rescue 
us from selective blindness." 
Awareness is a start. But it would require some inconceivable 
leaps — among them, that enemies acknowledge the flaws and 
strategies they have in common. "Devaluation reinforces your 
sense of Tightness," the author writes, "and both Osama bin 
Laden and George W Bush have made use of this tactic." 

A cult, Deikman writes midway through the book, "is some- 
thing that you yourself don't belong to. One's own group is... 
above such behavior." Nearly a hundred pages later, his book 
demolishes that satisfied idea. We gather in groups of same- 
ness. Conflict requires Them and Us; we are good only because 
they are bad. But we have never paid as high a price for our cer- 
tainty. These are among the most terrifying times in history — 
not least because America has helped to create them. ■ 

Elissa Eh 'S8 is a lecturer on psychiatry at HMS. 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 



BOOKS BY OUR ALUMNI 



ROOKSHF.IF 




THE NEW 
HARVARD 
GUIDE TO 
WOMEN'S 
HEALTH 





Trance & Treatment 

Clinical Uses oj Hypnosis, by Herbert 
Spiegel and David Spiegel 71 (American 
Psychiatric Publishing, 2004) 



This father-son team, both psychiatrists 
and psychoanalysts, delve into the 
human capacity for hypnosis and its 
use in treating patients. They debunk 
common myths — for instance, that 
hypnosis is a kind of sleep. Rather, they 
say, it is more akin to intense concen 
tration. Through examples, the authors 
discuss how to use the results of the 
Hypnotic Induction Profile to develop 
strategies for smoking cessation, pain 
control, and the treatment of asthma, 
anxiety, stuttering, and eating disor 
ders, among other problems. 

The New Harvard Guide 
to Women's Health 

by Karen J. Carlson '80, Stephanie A. 
Eisenstat, and Terra Ziporyn (Harvard 
University Press, 2004) 



This update of a 1996 edition includes 
recent advances, reversals, surprises, and 
challenges in women's health and aims to 
answer the kinds of questions physicians 
hear every day. In an A-to-Z format, it 
lists more than 300 problems or condi 
tions with entries that outline their 
basic physiology, typical symptoms, 
evaluation, treatment, and prevention. 
The authors give the latest recommenda- 
tions on heart disease, hormone replace- 
ment therapy, medications, procedures, 
screenings, and diagnostic tests. 



Growing Pathogens in Tissue Cultures 

Fifty Years in Academic Tropical Medicine, 
Pediatrics, and \ Urology, by Thomas H. Weller 
'40 (Science History Publications, 2004) 



Welter's epidemiological career took off 
with the research race to discover a 
polio vaccine and culminated with win- 
ning the Nobel Prize. Some of the most 
enjoyable aspects of this view of a life in 
science are the many engaging first-per- 
son accounts of political, geographical, 
and scientific challenges. Weller com- 
municates the excitement, heartbreak, 
and danger of contamination associated 
with his search for vaccines. 

A Write of Strings 

Selections from Thirty Years of Chamber 
Music Motes, by Craig B. Leman '52 
(Chamber Music Corvallis, 2004) 

This carefully researched book collects 
200 of Leman's concert notes and essays 
on some of the world's beloved com- 
posers and their finest works. Leman, a 
pianist and surgeon, peppers his com 
mentary with biographical details and 
irresistible anecdotes. 



Seascapes 

by Da\id Sanders Howell '47 (Howe/I, 2004) 



Howell's passion for both the sea and 
painting began in his early adolescence. 
Since his first art classes, he has stopped 
neither creating nor sailing, despite the 
restrictions on his time as internist, 



rheumatologist, and professor at the Uni- 
versity of Miami School of Medicine. This 
book's tranquil and thunderous scenes 
depict the majestic sea in its many moods 
and lights, from Maine to Miami. Howell 
chronicles his influences and develop- 
ment as an artist in an opening essay. 

Escape Fire 

Designs for the Future of Health Care, by 
Donald M. Berwick 72 Qossey-Bass, 2004) 



The author offers insights into providing 
quality care and suggestions for change, 
using medical and non-medical exam- 
ples — such as Captain James Cook's insis- 
tence on sening his crew sauerkraut to 
prevent scurvy — for inspiration. Berwick, 
chief executive officer of the Institute for 
Healthcare Improvement, delivered these 
essays as speeches at the National Forums 
on Quality Improvement in Health Care. 

The Mystery of Breathing 

A Novel, by Perri Klass '86 
(Houghton Mifflin, 2004) 



Pediatrician and waiter Perri Klass com 
bines mystery with medicine in her latest 
novel. Doctors and lay readers alike will 
feel at home in the NICU where neona- 
tologist Maggie Claymore devotes her 
time. She becomes the target of an anony- 
mous smear campaign that plays on the 
fears of contemporary doctors: liability 
and malpractice. Klass avoids an easy 
resolution to the novel's mystery and 
offers instead a heartbreaking conclusion 
with a surprising silver lining. 



AUTUMN 2004 • HARVARD MEDICA1 ALUMNI BULLETIN 



11 



BENCHMARKS 



DISCOVERY AT HMS 




A Laughing Matter 



OW MANY PSYCHOTHERAPISTS 

does it take to change a 
light bulb? Only one, but the 
light bulb has to really want 
to change. 

Once considered taboo, a jocular atti- 
tude — and the laughs it can inspire — 
can increasingly be found not only about 
the therapeutic encounter, but within it 
as well. The role laughter plays in psy- 
chotherapy has been disputed since the 
days of Freud. Some early therapists 
believed that their laughter 
could wound patients, while 
more recent thinking has held 
that, if used nonjudgmentally 
laughter can help support the 
therapeutic partnership. But 
none of those theories was 
based on objective data. 

In the October issue of 
The Journal of Nervous and 
Mental Disease, researchers 
from Massachusetts Gen- 
Hospital report the 



appropriate. We wanted to take an objec- 
tive look at the occurrence of laughter 
during therapy and measure its physio- 
logic effect." 

As part of a larger ongoing study of 
psychophysiology and empathy, the 
researchers — including coauthors Erin 



erai 

first physiologic evidence of 
the role of laughter during psy- 
chotherapy sessions. The investi- 
gators found that patients use laugh- 
ter to communicate emotional intensi- 
ty to their psychotherapists, much like 
an exclamation point at the end of a 
sentence. In addition, patients' and 
therapists' laughing together magnifies 
that intensity and may contribute to 
their rapport. 

"Current research on laughter in gen- 
eral shows it is more about communi- 
cating emotion than about humor," 
says Carl Marci '97, director 
of social neuroscience in the 
Department of Psychiatry at 
Massachusetts General Hos- 
pital and the paper's lead 
author. "Many therapists have 
been caught up in the old 
notion that laughter signifies 
only humor, even ridicule, 
and have questioned whether 
using laughter in therapy is 




The researchers found that patients 

use laughter to communicate emotional 

intensity to their psychotherapists, 

much like an exclamation point at 

the end of a sentence. 



Moran and Scott Orr — videotaped thera- 
peutic sessions and took physiologic 
measurements of both members of ten 
patient -therapist pairs. The patients were 
being treated for common mood and anx- 
iety disorders in pre\iously established 
patient-therapist relationships. Partici- 
pating therapists practiced psychody- 
namic therapy, an approach that uses the 
therapeutic relationship to help patients 
develop insight into their emotions. 
Throughout the therapy sessions, 
the physiologic responses of both 
patient and therapist were deter- 
mined by skin conductance 
recordings. These record- 
ings are commonly used to 
measure the activity of the 
sympathetic nervous system, 
which controls physiologic 
arousal and increases such 
parameters as blood pres- 
sure and heart rate. Earlier 
\J » studies have shown that 
laughter increases arousal 
and that elevated skin con- 
ductance is associated with 
increased empathy between 
therapists and patients. Fol- 
lowing the sessions, inde- 
pendent observers reviewed 
the videotapes and identified 
each laugh episode according 
to who was speaking prior to 
the laughter and whether the 
other person laughed as well. 
In the ten recorded ses- 
sions, the observers identified 
145 episodes of laughter. On 
average, patients laughed 
more than twice as often as 
therapists did and were 
most likely to be laughing 
in response to their own 
comments. Therapists also 
were more likely to laugh 
in response to what patients 
had said. The skin conduc- 
tance measurements showed 
that laughter produced 



12 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 



Research 




physiologic arousal in both patients 
and therapists, with arousal strongest 
when both laughed together. 

"We were surprised to find how- 
common laughter was in therapy — an 
average of 15 laughs per 50-minute ses- 
sion," Marci says. "Taken together with 
the current understanding of laughter 
outside of psychotherapy our findings 
suggest that the patient who is laugh- 
ing is trying to say more than has been 
expressed verbally to the therapist. 
Laughter is an indication that the sub- 
ject is emotionally charged." 

The relatively rare occurrence of 
laughter among therapists — and the 
fact that, when they did laugh, it was 
almost always in response to patient 
comments — reflects the focus of ther- 
apy on the patient's emotions, Marci 
says. He also notes that the therapists 
showed a physiologic reaction to their 
patients' laughter even when not 
laughing themselves, indicating an 
empathic response to their patients. 
When the therapists did laugh, the 
patients' physiologic responses went 
even higher, supporting the well 
known notion of the contagiousness 
of laughter and suggesting that, when 
therapists laugh with patients, the 
patients feel validation of the emo- 
tions they are expressing. 

"The clinical implications of the 
findings support the need for thera- 
pists to pay closer attention to when 
patients laugh during psychotherapy," 
Marci says. "Therapists should explore 
the meaning of what is said immediate- 
ly preceding the laughter." 

The researchers' next step is a 
longer term study that examines how 
the occurrence of laughter evolves as 
the therapeutic relationship develops, 
with the ultimate goal of finding 
any significant relationship between 
laughter and improved mental health 
for patients. In the meantime, jokes 
about the therapeutic relationship 
will surely continue. ■ 



DAMAGE PATROL 

The ungainly movements, dementia, and mood swings that characterize 
Huntington's disease result from a single mutation that kills neurons in a 
specific brain structure, the striatum. It now appears that this mutation trig- 
gers defects in other areas of the brain, and even in other parts of the 
body, yet these other cells somehow manage to survive. These findings are 
described by Ole Isacson, an HMS professor of neurology, and colleagues 
in the September Annals of Neurology. Isacson and his team are now turn- 
ing to new experiments that will try to elucidate cellular defense mecha- 
nisms. Their research may also increase understanding of other types of 
adult onset neurodegenerative diseases, such as Parkinson's disease, amy- 
otrophic lateral sclerosis, and Alzheimer's disease. 

HI* WOMAN WONDER 

A study by researchers at Beth Israel Deaconess Medical Center of amenorrheic 
women described in the September 2 issue of the New England Journal of 
Medicine shows that low doses of leptin resulted in restored ovulation for some 
patients, increased levels of reproductive and neuroendocrine hormones, and 
hinted at better bone formation. The findings have implications for very thin 
women who are dealing with problems of infertility, competitive athletes and 
dancers whose thin frames put them at risk for bone fractures and osteoporo- 
sis, and women battling eating disorders, such as anorexia nervosa, says 
Christos Mantzoros, HMS associate professor of medicine. 

m THIN RED LINE 

The largest clinical study of its kind shows that almost half of the complications 
and deaths due to in-hospital deep vein thrombosis (DVT) could be prevented with 
a daily administration of the blood-thinner dalteparin, according to results pub- 
lished in the August 1 7 issue of Circulation. DVT occurs in approximately two 
million people a year, more than 600,000 of whom are at risk of a blood clot 
migrating to the lungs and blocking the pulmonary artery. Pulmonary embolism 
is the third leading cause of death in the United States. According to Samuel 
Goldhaber, the study's senior investigator and an HMS associate professor of medi- 
cine at Brigham and Women's Hospital, "Patients who fit the profile — including 
those with cancer, or respiratory and congestive heart failure — should be con- 
sidered at risk for DVT or a pulmonary embolism and be closely monitored." 

H* HITTING THE SNOOZE ALARM 

A study in the September 27 issue of the Archives of Internal Medicine found 
that among people with chronic insomnia, advice from a therapist is more likely 
to produce a normal night's rest than Ambien, the top-selling sleep aid, whose 
sales reached $1 .5 billion in 2003. Sleeping pills should be prescribed mainly 
for people whose insomnia is caused by an event or illness, such as jet lag or 
the side effects of chemotherapy, according to the lead author of the study, 
Gregg Jacobs, an insomnia specialist at the Sleep Disorders Center at Beth 
Israel Deaconess Medical Center and assistant professor of psychiatry at HMS. 
Other insomniacs, Jacobs adds, are staying awake in part because of bad 
sleep habits that a behavior therapist can help change. 



AUTUMN 2004 • HARVARD MEDICAL ALUMNI BULLETIN 




I was funny once. 

At least, I once made Tommy Smothers laugh. I was 
tagging along with a college friend to a party at 
the great comedian's house in Los Angeles. When 
Smothers asked me what I did, I told him I was a 
monkey vivisectionist. He was so delighted that he 
gave me a bottle of cabernet sauvignon from the 
Smothers Brothers Vineyard. Sadly, though, I had 
not intended to be funny: my doctorate was in pri- 
mate electrophysiology. I had made Smothers laugh 
merely because he had expected to be bored, and I 
had caught him by surprise. 

While I spent college low on the evolutionary 
ladder, vivisecting slugs, that same college friend, Rob 
LaZebnik, was slaving over spoofs for the Harvard 
Lampoon. Most evenings found me on Premed Parkway, 
an infinite row of science library carrels whose monas- 
tic underground cement walls magnified every cough 
and crunch, while Rob more religiously spent his 
evenings watching Johnny Carson and David Letter- 
man. Taking notes. While Rob and his Lampoon friends 
like Conan O'Brien struggled to wedge themselves 
inside the door of such shows as Saturday 
Night Live, my premed friends and I 
went on to medical school as pas- 
sively as cattle on a conveyer belt. 

by Alice Flaherty 



14 



HARVARD MEDICAL ALUMNI BULLETIN 




c 

I 





When someone slips on 
a banana peel, why do we 

sometimes laugh — and 
sometimes call the doctor? 



A 



MWR 

Hi 



iK» 



■ 



Mel Brooks 
simply one's perspective: 'Tragedy is if I cut my finger 




1 








From Rob I learned that although 
laughter may well be the best medicine, 
prescribing Lipitor is much easier. Even 
now, when Rob is a well- established 
writer and producer of sitcoms, the 
strain he feels from having to be funny 
ten hours a day makes me grateful for my 
hospital's cheering atmosphere. This 
feeling — which comes from being sur 
rounded by people whose problems 
dwarf mine — borders on schadenfreude. 

We can perhaps make a case that the 
wall dividing comedy writers from doc- 
tors — masters of tragedy and propri 
ety — is not that thick. Comedians and 
doctors often emerge from similar back 



grounds — the great physician William 
Osier and the rubber-faced comic Jim 
Carrey grew up in neighboring small 
towns in Ontario, and the Brooklyn 
immigrant community that produced 
Nobel- Prize-winning neurologist Eric 
Kandel also gave us Woody Allen. 

An even thinner wall separates Conan 
O'Brien, renowned for his comic genius, 
from doctors. He spent the first 18 years 
of his life in the Brookline home of his 
lather, Thomas O'Brien '54, a Harvard 
Medical School microbiology professor. 
Conan's personal story would seem 
to control for both environmental and 
genetic influences. 



But comic and medical phenotypes 
remain distinct: Conan once told me 
how, during high school, his father had 
shepherded him into a summer job car- 
ing for mice in a Brigham and Women's 
Hospital laboratory. One slow day 
Conan put his murine charges on a tray 
tied helium balloons to the corners, and 
sent it wafting down the corridor. Fif- 
teen minutes later the tray floated back 
with a note: "Please return these mice to 
their cages." That was the end of Conan's 
medical career. 

It's not that doctors are never funny. 
There is The House of God, for example, 
the blackly comic bildungsroman that 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 



argues that what separates comedy from tragedy is 
Comedy is if you walk into an open sewer and die.' 



Stephen Bergman 73 wrote under the 
pseudonym Samuel Shem. Generations of 
premeds, and even normal people, have 
laughed out loud reading it — although, 
after residency, the book seems less like 
satire and more like simple reportage. 

We doctors could perhaps argue that 
we're not funny because our work is so 
bound up with tragedy. Comedy is not 
the opposite of tragedy, though. The two 
are enmeshed; they are both the opposite 
of flatness. Comedian Mel Brooks 
argues that what separates comedy from 
tragedy is simply one's perspective: 
"Tragedy is if I cut my finger. Comedy is 
if you walk into an open sewer and die." 

Larry David, co-creator of Seinfeld, 
believes that comedy is related to tragedy 
because in comedy, as in Olympic diving, 
you get points for difficulty. \ laking jokes 
about death becomes funnier because 
of its sheer riskiness — it provides your 
audience with an extra frisson from the 
likelihood that you will hit your head on 
the diving board on your way down. 

The neurologist V. S. Ramachandran 
draws his metaphor not from athletes, but 
from apes. He proposes amused laughter 
as a primate false-alarm call, a revocation 
of the need for help. If someone in your 
tribe slips on a banana peel and breaks his 
leg, you don't laugh — you call the doctor. 
But if he slips and gets up immediately, 
you laugh — at least if you're a monkey, 
or a human with a taste for slapstick. 

My chief exposure to primate humor — 
or, rather, nonhuman primate humor — 
came in graduate school. When bored, I 
would make rounds with the head vet in 
the animal facility, a huge underground 
zoo of frogs, mice, and primates. On those 
rounds the vet acted as simian play ther- 
apist, carrying a tin lunchbox of toys 
that he rotated with godlike impartiali 
ty through the cages to keep the monkeys 
from becoming bored. More successful 
than his slinkies and rubber balls, though, 
was the television set he kept tuned to 
reruns of Wild Kingdom and The Monkecs. 



Keeping the primates amused was 
deemed to be good for their health — 
pant-hoots, the ape equivalent to laugh- 
ter, as best medicine. The entertainment 
also kept the monkeys from masturbating 
all day, which was thought to be bad for 
graduate student morale. 

Ramachandran's false-alarm hypothe- 
sis fits with what little we know about 
how the brain controls humor percep- 
tion. Of great importance are parts ot the 
medial forebrain that help detect incon- 
gruity. Perceiving humor also activates 
the same centers for drive and pleasure 
that kick in during such wayward pas- 
times as gambling and cocaine use. 



As for the notion that laughter is the 
best medicine for humans, too, several 
recent research papers show that 
watching comedies such as that Marx 
Brothers classic, Duck Soup, can decrease 
pain perception. Then again, so can 
watching tragedies like Hamlet. Or even 
watching something merely gory, like 
Night of the Living Dead. Apparently the 
primary factor is that the stimulus be 
distracting and arousing enough. 

Control of the expression of humor is 
relatively well localized, much further 
back in the brainstem than is the percep- 
tion of humor. Pseudobulbar affect, the 
uncontrolled release of laughter or tears 



French Twist 

Moliere managed to twist tragedy into a comic medical masterpiece. 
The Imaginary Invalid is usually presented as a play about a healthy 
man who wants to be sick. For Moliere, who wrote it as he was in the 
throes of tuberculosis, it must equally have been about his own desper- 
ate desire to be a hypochondriac rather than a dying man. His doctors had urged him 
to abandon the theater because the exertion was hastening his death, but his farces 
were his life. He continued to work — indeed, he wrote the Invalid so he could also 
star in it, able to remain seated throughout the play, on a commode, coughing. 

Medicine didn't save Moliere; no doctor would come to his deathbed because of his 
scurrilous play — which portrayed physicians as tricksters profiting from making their patients 
believe they were ill — and if was just as well, since the preferred treatments of the day were 
bloodletting and high colonics. But comedy didn't save him, either: on the fourth night 

of the hugely successful 
play, Moliere suffered 
a lung hemorrhage 
and died, perhaps from 
the effort of projecting 
his voice to the laughing 
audience. Still, his 
use of comedy as 
a defense left us the 
greatest collection 
of enema jokes in 
Western literature. ■ 




AUTUMN 2004 • HARVARD MEDICAL ALUMNI BULLETIN 



humor activates the same centers for drive and 
pleasure that kick in during such wayward 
pastimes as gambling and cocaine use. 



without any experience of the appropri- 
ate triggering emotion, can occur when 
brainstem function is altered. One of my 
patients, after having a stimulator placed 
in her brain to control Parkinson's dis- 
ease, reported a new, involuntary giggle 
that embarrassed her at the golf club. 
When I changed the voltage on her stim- 
ulator, the giggle disappeared. 

Other pseudobulbar patients weep 
when they should laugh. One 
construction worker with a 
brainstem stroke, who sobbed 
every time I made a mild witti- 
cism on rounds, would then sob 
for real because his tears morti- 
fied him. 

Perhaps this anatomical link 
between laughter and tears could 
be used to argue, however fal- 
laciously, that a little comedy 
should be added to the daily 
practice of a profession as tragic 
as medicine. Humor may be 
merely an inappropriate psycho- 
logical defense against suffering, 
but even black humor is less cor- 
rosive than numbness. I learned 
this from a surgical chief resident 
who had one of the wickedest 
senses of medical humor I have 
ever encountered. On rounds, before we 
entered a patient's room he would dissect 
that patient — and the rest of the team — 
more accurately than any scalpel could. 

Yet as soon as he crossed the threshold, 
his bedside manner was unsurpassingly 
gentle. He never ignored the suffering of 
an opiate addict who was hypersensitive 
to minor pains, or the qualms of anxious 
patients with dozens of questions. 
Although his Janusian character troubled 
me, at least he was alive to his patients. 
And he brought them alive for the rest 



of us too, transforming the large-bowel 
obstruction in Room 818 into a character 
from Moliere's The Imaginary Invalid. 

For most doctors, the preferred 
defense against patients' suffering is to 
scrub it out of our minds. Nowhere is 
this avoidance more evident than in 
patient notes. These desiccated husks of 
patients' lives are dry not only because 
we must write them quickly, but also 




MARXIST EVOLUTION: Groucho Marx exploited the comic 
potential of impersonating a doctor not only in A Day at 
the Races, shown here, but also in Monkey Business. 



because we intentionally strip everything 
tragic or comic from them. Whether our 
dryness stems from a desire to be polite, 
to avoid litigation, or to stand on a 
pedestal of ponderous scientific rhetoric 
aimed at rendering our pronouncements 
more authoritative, by writing dull notes 
we do our patients a disservice. 

If our notes leave out everything that is 
human — such as the silk scarf an elderly 
Boston Brahmin has improbably found to 
coordinate with her johnny — we make 
our patients less memorable, and that 



makes it harder to treat them. Was the 
83F w/ COPD, CAD s/p CABG, and CRI 
the one with ALL=PCN? If the note- 
writer had impolitely quoted the patient's 
description of how taking penicillin 
"made me swole up," you'd remember. 

Wise families of ICU patients put up 
photos of the patients when they were 
young and healthy to appeal to our sense 
of tragedy and motivate our efforts to save 
what may otherwise look like 
shells of their former selves. Simi- 
larly, the patients who engage 
us with humor get more of our 
attention and therapeutic effort. 
When we respond to our 
patients only in measured tones, 
our advice is less memorable and 
our patients are less compliant. 
Humorlessness deadens human 
communication, which is, after 
all, propelled by emotion. Rather 
than spending millions of dol- 
lars developing a new blood 
pressure medicine that is mar- 
ginally more effective than last 
year's model, we should com- 
municate warmly and vividly 
enough to our patients so that 
they even bother to take the 
pesky pills in the first place. 
Of course, it's not fair to say that 
all doctors are white-coated pillars of 
grimness. At Massachusetts General 
Hospital, where I work, psychiatrists 
seem to be the best at putting humor 
to use. George Murray, for example, has 
earned renown for progress notes that 
will burn a patient into the reader's 
memory forever. Unfortunately, the 
best are too scatological to repeat in an 
alumni publication. 

In the psychiatric interview, humor 
can open patients up — or intentionally 



18 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 



close them down. Once I watched John 
Herman, director of clinical services in 
the hospital's psychiatry department, 
interviewing a depressed woman who 
had never seen a psychiatrist before. 
Although she was ashamed to be there, 
and guarded, his humor relaxed her. She 
was soon describing her feelings so open 
ly that she was on the point of tears. He 
quickly made a joke, and she collected 
herself. Afterward he asked me why I 
thought he had cracked the joke. 

"Because you're a guy! Guys hate to 
see people cry," I replied, with all the 
psychiatric insight that comes from 
being a neurologist. 

"No!" he exclaimed, delighted that I 
had fallen into his pedagogical trap 
"Some patients like to cry; they find it 
cathartic. But not this one. Self-control 
was very important to her. If she had 
cried, she would have been so embar- 
rassed that she would never have 
returned for her follow up appointment." 

The king of psychiatric humor at our 
hospital may be Ned Cassem '66, the 
former department chief. Cassem, a 
Jesuit priest, does much of his work in 
end of life issues; he even heads the 
hospital's Optimum Care Committee, 
usually called the God Squad. Is his 
ability to be funnier than usual in a role 
that is gloomier than usual simply one 
more piece of evidence for the link 
between comedy and tragedy? 

Cassem uses humor to make teaching 
points memorable to residents, as when 
he reminds them, with an aphorism, that 
a family history of suicide escalates a 
patient's suicide risk: "Suicide is putting 
your skeleton in other people's closets." 
He makes his advice memorable to 
patients in similar ways. Once, for exam- 
ple, he was asked to speak to a family who, 
for religious reasons, wanted medical 
treatment withheld from a relative. 

"We know that Jesus is watching over 
her," the son told Cassem. 

"I'm sure He is," Cassem replied, "but 
I've checked, and He's not lea\ing notes in 
the chart. So for day-to-day management, 
I think He's leaving decisions to us." 

Non-psychiatrists sometimes dismiss 
humor, along with the other emotions, 
as psychiatric turf. Studies have shown, 
though, that even pathologists and neu 
rologists can be funny on occasion. On 
rounds when I was a resident, I used to 



copy down the clinical pearls the neurol- 
ogy attendings uttered. Soon I had a 
spin-off column in which I was record 
ing the funny things they muttered. The 
first column became a handbook of neu 
rology; the second would have to be pub 
lished under a pseudonym. Nonetheless, 
funny bits from the second column kept 
trying to creep into the first. My editors 
rooted out most of them. One fragment 
that escaped the censors into the hand 
book, though, was the jingle Michael 
Schwarzschild '85 composed for the 
Movement Disorders Consult Service: 
Trouble with tone? 
Just pick up the phone. 
Jerky or stiff? 
We're there in a \\ff. 

Unfortunately, when the jingle hit the 
Spanish edition it was translated literal 
ly, as straightforward clinical advice: "If 
you are experiencing muscular rigidity, 
utilize the telephone, please." I have not 
yet had the nerve to find out what hap 
pened to the poem in the Japanese edi- 
tion; I hope it became haiku. 

Later, when giving talks about a sec- 
ond book, 1 was pleased that the audi 
ence generally laughed much harder than 
the jokes deserved, but I was taken 
aback to find that their laughter was so 
tinged with relief. "Thank you so much 
for being funny," one woman said after 
one of my talks. "When I saw you were a 
doctor I was sure this would be boring." 

I found that the tighter I rolled my 
bun and the duller I dressed, the more 
my humor caught the audience off guard. 
An advantage that doctors have over 
comedians, then — besides better job 
security — is the element of surprise. 
Because no one expects doctors to be 
funny, our patients are grateful for even 
the mildest joke. And, although stress- 
related illnesses and depression are high 
er in both comedians and doctors than 
in the general population, at least we 
doctors know better how to work the 
medical system to get ourselves treated. 

Then again, we never get invited to 
host the Oscars. ■ 

Alice Flaherty '94, PhD, a neurologist at Mass- 
achusetts General Hospital, is author of The 
Massachusetts General Hospital Hand 
book of Neurology and The Midnight 
Disease: The Drive to Write, Writer's 
Block, and the Creative Brain. 



Glad 
Science 



People with heart disease are 40 
percent less likely than healthy 
people to laugh often and to use 
humor to extricate themselves from 
uncomfortable situations. 

[International Journal of Cardiology, 
2001;80:87-88] 



Primary care physicians with no 
medical liability claims filed against 
them tend to laugh and to use humor 
more often with patients than those 
with claims against them. 

[JAMA, 1997;277:553-559] 



One study found that skin welts 
shrank in allergy patients who 
watched Charlie Chaplin's classic 
comedy Modern Times, but not in 
patients who watched a video about 
the weather. 

[JAMA, 2001,285:738] 



The nucleus accumbens — the 
same region of the brain that has 
been shown to be activated by 
rewarding drugs such as cocaine 
and amphetamines — is activated 
when a person sees or hears 
something funny. 

[Neuron, 2003;40:1041-1048] 



Researchers have found a relationship 
between a decline in cognitive abilities 
in the elderly and a higher error rate 
in picking out humorous punchlines 
and cartoons. 

[Journal of the International 
Neuropsychological Society, 
2003;9:855-863] 



AUTUMN 2004 • HARVARD MEDICAL ALUMNI BULLETIN 



19 



R 



/ 



V 






1 



/: 






Medical training 
can warp your sense 
of humor — and 
humor can help 
you make sense of 
your medical training 




20 HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 




by Perri Klass 



DID YOU HEAR THE ONE ABOUT THE TEENAGE GIRL WHO 

went to the health center for an itchy insect bite and 
ended up taking a pregnancy test? Or the one about 
the constipation epidemic during an on call weekend? 
Or that knee shipper about the grandfather who start- 
ed having chest pains on the baby ward, where the 
only oxygen masks available were sized for infants? 

These are the kinds of unfunny things I find funny. 
I've been writing about medicine ever since I entered 
medical school, and I'm afraid I've often succumbed to 
the easy temptation of presenting myself in print as 
rather noxiously sensitive. 

But every so often I catch myself in some unduly 
smug and self-congratulatory locution, and I pause, as 
an imaginary conga line of pediatric residents comes 
snaking across my brain. And what's that lyric they're 
singing? Could it be, perhaps, my own catchy ditty: "He 
was too young to come out of his mother/He should 
have stayed on inside and been fine/He was too young to 
come out of his mother/He got a tube and a vent and a 
line It was an itsy bitsy teenie weenie hypercarbic seiz- 
ing preemie." You get the idea. 

As a resident, I probably laughed harder over our 
hospital housestaff shows — writing, rehearsing. 



» 




AUTUMN 2004 • HARVARD MEDICAL ALUMNI BULLETIN 






I don't 
at the expense of other doctors — I'm too 



performing, and watching them — than I 
have ever laughed over anything. I still 
giggle when I think of some of our finer 
moments — although, out of a strict 
HIPAA-inspired sense of confidentiali- 
ty, I shall not reveal so much as a single 
lyric, line of dialogue, or even sight gag 
that was not my own, thereby sparing 
my residency colleagues — all no doubt 
highly distinguished leaders in their 
fields today — much embarrassment. 

I know, of course, why I laughed so 
hard. It was because I desperately need- 
ed to laugh, because I was so deeply 
engaged in learning how to be a pedia- 
trician, and because I was so anxious 
and scared and charged up and sleep- 
deprived. It was because I was living close 
to the edge of other people's tragedies and 
laughing in the face of a new and pro- 
found understanding of the vulnerabili- 
ty of human life. 

Humor thrives on tension and anxi- 
ety — and sometimes, let's be honest, on 
hostility. One of my fellow residents told 
me that two particular lines from one of 
my songs in our holiday show — sung to 
the tune of "Comedy Tonight" — gave 
him his happiest residency moment. 
Like all of us, he had spent many com- 
plicated nights in the newborn inten- 
sive care unit and many agonizing 
mornings second-guessing the ethical 
implications of the decisions he had 
made. It felt so good, he said, to stand 
on stage, face the whole gang of our 
teachers, and belt out, after a chorus of 
"Old malformations, new complications," 
these lines: "We save their lives, we are 
so clever!/And then their parents get 
them forever!" And yes, it was just a lit- 
tle bit hostile — toward our mentors, 
toward the mingled expertise and help- 



lessness of our profession, and perhaps 
even toward the tragic complexities of 
life and death. 

Maybe I've always had a warped 
sense of humor. Maybe we all do — a 
particular is-nothing-sacred kick often 
distinguishes successful humor, and 
there is always relief in laughing at the 
things that scare you, rile you, worry 
you, or haunt you. But as I became a 
doctor — as medical material became 
the very stuff of my life — I stopped 
noticing that there was anything twist- 
ed about medical humor. 

Every workplace features its unique 
brand of humor, I suppose, just as every 
workplace has its own rules, traditions, 
and jargon. Air traffic controllers (talk 
about tension and anxiety) probably 
make bad pilot jokes, and w r e're just as 
glad not to hear them. For all I know, 
there are strong traditions of florist 
humor, gas station attendant humor, 
even mortician humor. But medical 
humor has an especially grand — or 
especially tawdry — pedigree. 

After all, we are a profession with a 
tradition of hierarchy and even pompos- 
ity, which always fuels rich opportuni- 
ties for humor at the expense of those in 
the upper echelons — just ask anyone who 
has ever served in the military. 

We also deal with bodily functions, 
and as the mother of a fourth grade boy, 
I can attest to the profound and — if you 
will pardon the expression — gut-level 
appeal of any humor based on the nois- 
es, aromas, and substances produced by 
the human body. We all know that, 
despite their limited understanding of 
pathophysiology and biochemistry, my 
son and his ten-year-old friends could 
appreciate many of the jokes in your 



standard medical school show; orifices 
are just enduringly funny. 

Our training involves a deliberate 
attempt to help us discuss all these bod- 
ily functions without any sense of embar- 
rassment — in other words, all the good 
work I am doing with my fourth-grade 
son about what is not funny, especially 
at the dinner table, will go right out the 
window should he ever find himself in a 
medical training program. 

Doctors have to cope with life and 
death — or with the idea of life and 
death — and with the frailties of the flesh. 
This engenders a certain kind of tension, 
brought about, no doubt, by our enforced 
confrontation with certain bleak reali- 
ties that others might prefer to escape by 
denial. And this tension, in turn, cries 
out to be broken, and to be broken with 
humor, the blacker the better. 

I grew up watching famous doctor 
faces on television — not only Marcus 
Welby's furrowed brow, but also Hawk- 
eye Pierce's sloppy grin on M*A*S*H. So 
it was with zeal that, a few years ago, I 
tried writing a sitcom about medical 
school. I was working with my brother, 
a screenwriter by profession, and 
together we assembled a fictitious group 
of medical students and then enjoyed 
ourselves at their expense. 

I tried to write about the academic 
tension gripping our characters as they 
began their first year — and then to 
show them kicking back, acting sillv at 
a party, and ending up in dubious 
romantic entanglements. I exploited 
their propensity toward self-diagnosis 
in the virginal supernerd who became 
convinced that he had mysteriously 
acquired a sexually transmitted dis- 
ease and kept coming up with unlikely 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 



have time to engage in coarse, insensitive, tasteless jokes 
busy telling stories on my patients and their families. 



diagnoses ("Oh, no. I have mucocuta 
neous leishmaniasis!"). 

But whatever hijinks we came up with 
weren't edgy enough for the TV people; 
they kept asking us to "ratchet it up." 
Thus, my poor medical students ended 
up playing pin the penis-on the-cadaver 
at their party — did I miss this in medical 
school? was I just not invited to the right 
parties? — and my poor virginal super- 
nerd had a run in with a singularly well 
equipped yet vindictive young woman 
who superglued kitty litter to his groin 
("Oh, no, I have leprosy!"). And, even after 
all that, the network mysteriously turned 
its back on our biting medical satire. 

But now I'm a grownup doctor, right? 
Those silly madcap medical school and 
residency days are far behind me. I may 
suppress a giggle at the memory of cer- 
tain tasteless lyrics I once had something 
to do with authoring, but those were my 
pressured, sleep-deprived training days. 
Now, I am pleased to report, I have 
become a matriarch, an authority fig- 
ure — oh, hell, let's admit it, I have become 
that common residency figure of fun — 
the LMD, the pain-in-the-neck local doc. 

Now it's me on the other end of the 
phone late at night trying to convince 
the Emergency Department resident 
that, despite the results of his review of 
the literature, I sent the kid in for a head 
CT and that's what I want, damn it. And 
yes, I can just imagine the faces that res- 
ident is making as he listens to my dia- 
tribe — and yes, I can imagine his choice 
of words — and I'm sure they are 
choice — when he finally gets to hang up 
on me and report back to his colleagues. 
But these days I don't have time in my 
busy schedule to engage in coarse, insen- 
sitive, tasteless jokes at the expense of 



other doctors — I'm too busy telling sto 
ries on my patients and their families. 

Oh, I have my standing jokes at the 
community health center where I work, 
such as the taxi- voucher family and the 
lady obsessed with getting her child 
door-to-door transportation from the 
public school system, even though the 
child seems perfectly healthy. And yes, of 
course, I know there are serious issues 
here — as I talk to the social worker of 
the family who can't keep their children's 
primary care appointments without 
constant taxi vouchers to transport them 
hither and yon, or as I consider the possi- 
bilities of Munchhausen's by proxy in a 
mother who seems determined to pin 
some drastic diagnosis on a healthy child. 

But it also makes for a funny story, a 
wait'll you hear this one moment, when 
I hang up the phone and turn to my col- 
leagues, who have been listening with 
interest to my side of the conversation 
("Well, the public schools have gotten 
pretty strict these days — I don't think 
they'll agree that he needs door-to-door 
transportation just because his fingers 
get cold — have you thought about buy- 
ing him warmer gloves?"). 

And I can't help it, there's also a laugh to 
be had when that teenager comes in for 
something to make her mosquito bite stop 
itching and then casually mentions, as she's 
leaving with her prescription for hydrocor 
tisone cream, that she hasn't had her period 
in six weeks, and no, she hasn't been really 
careful about using condoms every time, 
and also, she's been ha\ing this discharge. 
If you have ever practiced adolescent pri 
mary care, you should be laughing by now. 

So you laugh in recognition, and some- 
times in appreciation — for all my medical 
authority and privileged social status, I 



am easily intimidated, and some part of 
me can't help cheering for even the most 
difficult patients who have the sheer gall 
to stand up to doctors, the hospital, or the 
medical system, even if it's just to try to 
weasel more taxi vouchers. And you laugh 
at yourself, of course — if you don't have 
some good stories about diagnoses you 
failed to make or patient relationships you 
mishandled, if you aren't the butt of a good 
many of your own funny stories, then 
you're in danger of entering the twilight 
world of the terminally self righteous. 

So medical humor is still my way 
of acknowledging the unpredictability 
of reality, even when the weight of all 
evidence-based medical knowledge is 
brought to bear. As it said on a sign I used 
to see hanging on office doors back when 
I was a graduate student in biology, 
"Under the most rigorously controlled 
conditions of pressure, temperature, 
humidity, and other variables, the organ 
ism will do as it damn well pleases." 

Pathogens don't always do what they're 
supposed to do. Patients and their fami 
lies don't always do what they're sup- 
posed to do. Hospitals don't always do 
what they're supposed to do. Insurers 
never do what they're supposed to do. 
And most of all, of course, doctors don't 
always do what we're supposed to do. 
Could it be that humor, even terrible 
humor, is something of a saving grace? ■ 

Petri Klass '86 is an associate professor ofpcdi 
atrics at Boston University School of Medicine, a 
pediatrician at Dorchester House Health Center, 
and the medical director of Reach Out and Read. 
Among her recent books are The Mystery of 
Breathing, a novel and, with Eileen Costello, MD, 
Quirky Kids: Understanding and Helping 
Your Child Who Doesn't Fit In. 



AUTUMN 2004 • HARVARD MEDICAL ALUMNI BULLETIN 



as> 



A young Jazz Age intern worries that 

some improvised words at a 
deathbed may well prove to be his last 




WAS THE FIRST DAY OF MY INTERNSHIP AT THE 



Boston City Hospital and after some cursory instructions from my depart- 
ment chief, I was on my own. The telephone rang, and the nurse who 
answered it said I had better get over to Ward K and pronounce a man 
dead right away or there would be hell to pay. They had been looking for 
me all afternoon and where the devil was I? I knew nothing about pro- 
nouncing anyone dead, so I started out with much misgiving. 

En route, I ducked into the hospital library, where a young lady said she 
had nothing listed on this matter, but the information I needed was proba- 
bly on file in the superintendent's office under "Lex Mortem Dictu." I 
headed straight to that office, where I found only an old man who acted 
as messenger boy for the first assistant; he had worked there for many 
years but couldn't remember just exactly how to pronounce a man dead. 
Perhaps, he suggested, I should ask another intern or a nurse; someone, 
he was sure, would be happy to enlighten me. 

Unfortunately I met no one on my way to Ward K. When I finally arrived 
I found a huddle of frowning nurses with their arms folded tightly across 
their chests. They had been waiting almost an hour for me, they said, and 
they could not move the body until a doctor had officially pronounced the 
man dead. Furthermore they needed the bed for another patient. They were 
clearly in no mood to answer my questions about the proper procedure, so 
I reluctantly made my way through the unfriendly cluster to the middle of 
the ward, where a bed was screened. I entered the enclosure to find it 
crowded with nurses and orderlies. 



24 I HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 




I 





I reached the head of the bee 
He was unquestionably deac 



When I reached the head of the bed I 
slowly pulled down the sheet, exposing 
an emaciated man. He was unquestion- 
ably dead because the nurses had been 
waiting for nearly an hour, but was that 
sufficient evidence? Had the usual tests 
of death been made? What were these 
tests and who had made them? I some- 
how had to conceal my inexperience. 

I fumbled for the maris pulse; his skin 
was ice cold but I thought I could just 
detect a faint yet rapid pulse until I 
realized that I was gripping his wrist so 
tightly that the pulsation was mine. I took 
out my stethoscope and listened intently 
to his chest, but I could hear no sounds. I 
then opened his eyelids and noted that 
the pupils were unequally dilated. By this 
time I could sense considerable rustling 
among the nurses and orderlies. I over- 
heard tense whispers about hurrying it 
up and getting the job done already. 

I continued to examine the man, 
though, desperately hoping that some- 
one would finally give me a clue about 
the next step. But I could gather noth- 
ing constructive from the undertones. 
So I finally straightened up, looked 
significantly at the head nurse, and 
declared that she was correct: the man 
had undoubtedly expired. 

She snorted and exclaimed loudly, so 
everyone in the ward could hear, "Just go 
ahead and pronounce the man dead and 
stop all this nonsense!" 

I began to feel weak. The thought 
occurred to me that the repeated use of the 
word "pronounce" must bear some special 
significance; it must mean that something 
must be said in a particular way, with 
some particular legal phraseology. I dimly 
recalled seeing a play in which a character 
had died and the attending doctor had 
made a public statement. I tried desper- 
ately to recall what he had said, and then 
suddenly remembered a few words that 
seemed to cover the situation. 

With all the dignity I could summon, 
I intoned the following statement: "By 



virtue of the authority vested in me by the 
Commonwealth of Massachusetts and in 
accordance with the rules and regulations 
of the Health Department of the City of 
Boston, I, Dr. Hyman, a duly authorized 
intern of the Boston City Hospital, do 
hereby and hereon officially pronounce 
this man dead, and in witness thereof 
I hereby and in the presence of these 
witnesses set my hand and signature." 

When I finished, a stunned silence 
seemed to settle over the onlookers. 
The head nurse in particular looked 
shocked, and I was no little alarmed at 
her pallor when I asked for the certifi- 
cate to be signed. After a moment's hes- 
itation, she retrieved a slip of paper 
from her desk. I quickly initialed it and 
then strode out of the ward. At the door 
I turned and saw everyone still frozen in 
an oppressive hush. 

On my way back to the main wards I 
again felt weak as I wondered how much 
of the ceremony I had fouled up; I had 
obviously done something quite con- 
trary to the usual procedure. A grum- 
bling yet jocular throng had turned 
deeply solemn upon my pronouncement. 
The more I reviewed the situation the 
more worried I became. I resolved to ask 
the first house officer I met how I could 
extricate myself from this mess. 

It was getting late and although I had 
no appetite I went to the dining room 
hoping to run into my senior attending. 
But only a few interns were there and the 
waitress had begun to scold me for com- 
ing in so late when the telephone rang. 
"If you're the new intern and your name 
is Dr. Hyman, you'd better get up to 
the superintendent's office right away," 
she said. "But have a cup of coffee first, 
because you're going to need it." 

I gulped down the hot brew and 
bounded upstairs. If the front office was 
calling me, I was definitely in trouble 
because I had heard that only a few com- 
plaints ever reached the stage where the 
superintendent was called in. If this was 



happening on my first day at the hospi- 
tal, my future was dim indeed. 

It was with a heavy heart that I entered 
the office. The superintendent was pac- 
ing up and down and seemed to be argu- 
ing with several of his assistants. When 
I opened the glass door, they all looked 
rather savagely at me. I felt queasy. The 
first assistant wasted no time in yelling, 
"What the hell have you been doing in 
Ward K this afternoon? You've turned 
the whole hospital upside down. 
Couldn't you pronounce a man dead 
without raising all this rumpus?" 

Then the superintendent, a kindly 
man, interrupted and said, "Now young 
man, will you please tell us exactly what 
went on in Ward K?" 

So I explained the situation, prefacing 
my remarks by saying that I was not 
familiar with the "Lex Mortem Dictu" in 
use at the hospital, so I had substituted 
Section 110 of the 1905 Code. Everyone 
stared at me, and then the superinten- 
dent said, "Please tell me the exact state- 
ment that you made." I repeated my earli- 
er pronouncement word for word, with 
as much dignity as I could muster. 

Again a stunned silence fell. Finally 
the superintendent turned to the first 
assistant and said, "Charlie, first thing in 
the morning run down to City Hall and 
get a copy of that Section 110 of the 1905 
Code. It's about time we did this thing 
right; I've been here damn near 26 years 
and it's the first time I've ever heard the 
proper way of pronouncing a man dead." 
Then he said to me, "All right, young 
man, you did the right thing. Just forget 
about the rough way we were handling 
you. Goodbye and thank you very much." 

I returned to the w 7 ards in an even 
gloomier mood than before I had been 
summoned; I cursed myself for citing the 
1905 Code. Why hadn't I had the courage 
to confess my ignorance? I was in a worse 
mess now. When they looked up that 
code there would be nothing in Section 
110 — if there even was such a section — 



26 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 



I slowly pulled down the sheet, exposing an emaciated man. 
because the nurses had been waiting for nearly an hour. 




that had anything to do with pronounc- 
ing someone dead. I found the house offi- 
cers' quarters and stumbled into bed. 

The next morning, I was relieved when 
my department chief smiled as I told him 
about my predicament. He had heard all 
about it from the front office. "Chief," 
I said, "I didn't want to confess this 
to anybody, but I honestly don't know 
how to pronounce someone dead. There 
was nothing in the notes you gave me yes- 
terday. Tell me, how docs one do that?" 

The chief looked at me for a long time. 
Finally he said, "My boy, you have asked a 
question that every physician who has 
ever been present at the death of a patient 
has pondered. I know of no hospital with a 
specific ritual for pronouncing a man dead. 
By word of mouth, one intern conveys the 



traditional method of the institution to 
another and eventually the pronounce- 
ment of death may become just a nod of the 
head. Yesterday you inadvertently stirred 
up a problem with no special solution. It 
was lucky that you remembered that Sec- 
tion 110 of the 1905 Code. But for now the 
front office has a hot potato in its hands, 
and I advise you to keep away from that 
part of the hospital." He then led the way 
into the operating room, and we said 
nothing further about the matter. 

Pending a continued search for Sec- 
tion 110 of the 1905 Code, the superin- 
tendent issued a memorandum about 
the procedure to be followed in pro- 
nouncing a patient dead. It stated that 
henceforth house officers should con- 
duct themselves with decorum and 



confine their remarks to a simple state- 
ment, the text of which had been care- 
fully typed into the body of the memo- 
randum. Reading it, I was astonished to 
find my speech replicated verbatim, my 
own feeble recreation of words a stage 
actor had uttered so many years before. ■ 

Albert Hyman '18 was a cardiologist whose 
interest in cardiac resuscitation led him to wit- 
ness numerous patient deaths early in his career. 
In the 1930s, together with his engineer brother, he 
invented and patented the "artificial pacemaker." 
Operated by a hand crank and a spring motor that 
turned a magnet to apply electricity, the device was 
a breakthrough, though it was not widely accepted 
by the medical community at the time. This essay 
was excerpted from an article that appeared 
in thefanuary 1955 issue of the Bulletin. 



AUTUMN 2004 • HARVARD MEDICAL ALUMNI BULLETIN 



27 




Keeping a straight face isn't 
always all it's cracked up to be 




[in the clinical encounter] 



AMONG THE GREAT HAZARDS OF LIFE, NOT TO MENTION MEDICAL PRACTICE, IS THE 

sudden impulse to snicker at precisely the wrong time or in the wrong setting. 
And the nasty truth is that nothing is more irresistibly funny than when your 
laughter bubbles up exactly under these conditions. 

Church services are classically wrong time, wrong place. My sharpest 
early memory of uncontrollable and discreditable giggling comes from the 
time my Auntie Mame — her real name — hauled me, at the age of ten, to a 
small church north of Seattle. During the service Mamie suddenly nudged 
me, grinning, and pointed to a plaque on the wall. It paid tribute to the 
"pioneer women of Woodland," which long before had been a settlement in 
the area. Mamie's joke was at best a weak one. The community had since 
dwindled to a dilapidated roadside tavern, so the plaque now seemed to 
commemorate these spirited women's founding of a disreputable bar. 



» 



by 



William Ira Bennett 



■ 



28 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 



i 




N 





\ 




BEKJM0N 

is, from time to time, to appear ridiculous. 




Had I not been surrounded by strangers 
engaged in holy behavior I would have 
barely glanced up from my sneaked-in 
book, shot Mamie a condescending 
smile, and returned to my surreptitious 
reading. But we were in a church — and 
the church was packed. I immediately 
began a series of small respiratory explo- 
sions that swiveled all praying heads 
toward my deliriously amused self. Only 
Mamie's complicity protected me from 
the thin-lipped consequences of Luther- 
an disapproval. 

One's psyche survives this sort of 
thing with relative ease and a clean con- 
science. No element of the personal had 
played a part — I was mocking nobody's 
physical appearance or habits of speech, 
nobody's taste in clothing or love. Unfor- 
tunately a titter without a whiff of 
mockery is more the exception than the 
rule. Often when the urge wells up, it is 
precisely because someone else has tum- 
bled into ridiculousness. 

To be human is, from time to time, to 
appear ridiculous. This sad axiom has 
an unhappy corollary: from time to time, 
someone else wall notice. With any luck 
the person witnessing our descent into 
the ludicrous kindly empathizes with the 
gaffe, or has already achieved sainthood 
and is above it all, or has practiced yoga 
breathing for decades and can suppress 
laughter indefinitely. But none of these 
conditions is common, so the likelihood 
is high that one will eventually become 
the instigator or the recipient of an 
urge to titter. 

Another home truth is that intimacy 
and silliness go together like love and 
marriage. Indeed, the backbone of a solid 
relationship has to be the sheer willing- 
ness to tolerate a partner's descent into 
ridiculousness. Absent such tolerance, a 
divorce court is the likely next stop. 

The patient-doctor relationship is a 
perfect setup for ill-timed laughter. The 
clinical encounter is intimate, so one 
party or the other is always at risk of 
getting caught in a moment of absurdity. 



(I exempt from this discussion the mere- 
ly humiliating, which is never an occa- 
sion for laughter. A great deal of medical 
practice is humiliating for patients, and 
all involved must soldier on as though 
they hadn't noticed. I remain aston- 
ished, for example, at the sangfroid of 
my gastroenterologist.) 

While the patient may be relatively 
uninhibited in expressing mirth, the 
physician had damned well better con- 
ceal all signs of amusement until the 
patient is safely out of earshot. Divorce 
courts are bad enough; malpractice liti- 
gation has to be worse. But this is also 
exactly the problem. What is forbidden, 
as Adam learned to our universal cost, is 
the most tempting. 

I first began to think about the vicissi- 
tudes of tittering over a decade ago, when 
I was locked in unintentional combat 
with a patient who had concluded, on a 
week's acquaintance, that I was ruining 
her life in every possible way. We had 
been discussing whether I would issue 
her a pass to leave her psychiatric unit for 
a few hours, but our conversation rapidly 
devolved into her sermon on my resem- 
blance to Cain, Esau, and Judas Iscariot. 

It was, in its way, a bullfight, with me 
as lumbering bull. Every time I thought 
it was over, there was another shake of 
the cape, another verdict, and always 
the glint of steel as she waited for me to 
make my misstep. The pressure was 
building, because the only resolution to 
our face-off I could imagine was that I 
would burst into helpless laughter, 
whereupon she would neatly clip off my 
ears and tail, and I would need, at the 
very least, another profession, if not 
reconstructive surgery And all the while, 
I was baffled by my impulse to laugh, 
because on the surface our conversation 
was more exasperating than funny. 

Having matured a bit since Mamie 
had taken me to church, I held on during 
the harangue, although it was becoming 
ever less clear how I could both breathe 
and continue the conversation. Then, at 



the last possible moment, the patient 
stopped and drew herself back. She 
looked at me and then at her knees and 
said, "Now you're going to laugh at me. 
just the way my father always did." Noth- 
ing made me love her more than that 
magic moment when she dropped the 
cape, tossed the sword aside, and showed 
me the way back to the bullpen. Or, more 
accurately, she showed me her psycho- 
logical script and pointed out the role 
in her internal drama that I had, both 
unwittingly and guiltily, taken up. 

So I got off easy. But this experience 
started me on a search in both the medical 
literature and real, honest-to-goodness 
literature for some guidance on the topic 
of physicians tittering out of turn. It was, 
as you might imagine, a nearly dry well. 
Almost everything else that a doctor can 
do badly or wrong is amply covered — 
largely in Madame Bovary, if you ignore the 
adultery and stay with the good parts. 
But I know of only one solid source on 
the problem. It is a luminous episode in 
Woody Allen's otherwise puerile 1972 
film Everxthing You Always Wanted to Know 
About Sex (But Were Afraid to Ask). 

My movie guide gives EYAUTKAS 
(BWATA) three stars, which can only be 
explained by the segment starring Gene 
Wilder as Doug Ross, a mild-mannered 
physician. The doctor is in his office 
when a shepherd walks in, insisting on 
an appointment. The shepherd gradually 
makes clear to the doctor that he has suc- 
cumbed to one of the hazards of his pro- 
fession, falling madly in love with a sheep. 
We watch as Dr. Ross absorbs what he has 
been told and then, for 23 seconds (I've 
counted), keeps himself from bursting into 
laughter. The camera remains on Wilder's 
face as the actor puts in a half minute 
that transcends his entire performance 
in Willy Wonka and the Chocolate Factory. 

Dr. Ross successfully keeps himself 
from tittering, but he wants to titter, 
and the rest of Allen's tiny masterpiece — 
approaching Madame Bovary in subject 
matter and intensity — hinges on this ter- 



30 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 



rible fact. Confident of his ability to resist 
her charms, Ross meets the ewe. He soon 
succumbs and then risks — and loses — 
everything for her. In Allen's later doctor 
movie, Crimes and Misdemeanors, an oph 
thalmologist has his mistress rubbed out, 
but he gets off relatively easily compared 
with Dr. Ross, whose far graver crime 
was, after all, that he condescended to the 
shepherd's desire and /elf like snickering. 

We must not imagine, however, that 
condescension is only the doctor's risk, 
whereas ridiculousness is only the 
patient's. Like Falstaff, I have been 
dumped more than once into the laundry 
hamper of a patient's amusement and 
have learned that horror and humor sur- 
reptitiously hold hands. 

Not long after I stopped myself from 
chuckling at one patient's accusations of 
sabotaging her life, I was treating another, 
much older woman, who was confined 
to a dilapidated psychiatric ward against 
her will. Her state of mind was such that 
she would exchange few words with her 
captors, me the chief among them. She 
would sit erect in the day room of the 
ward and provide only her name (a false 
one), rank (fanciful), and serial number 
(which did not correspond with the med- 
ical record, but who was I to quibble?). 

This patient knew me as the archfiend, 
but every day I would saunter by and ask 
how she was doing as though I were 
utterly ignorant of my status in her cos- 
mology. One morning I found her in her 
usual spot sitting near half a dozen other 
patients, all of them quietly preoccupied 
with their own thoughts. I went through 
my routine, asking her how she was. 

"You're asking me how I am," she said. 
"Why are you asking me how I am?" 

Delighted at the opening, I rushed in. 
"Well, I'm your doctor," I said brightly, 
"so it's good for me to know how you 
are." I thought the patients nearby smiled 
slightly, approving of my good humor 
and good faith. 

She waited a beat. "You say you are a 
doctor," she answered, sitting ever so 




EMBR ACEABLE EWE: In Everything You Always Wanted to Know About Sex (But Were 
Afraid to Ask), Gene Wilder's character, a primary care provider, comes to rue his 
mirth at the expense of a sheep-besotted patient. In the final shot, the ruined doctor 
is seen sprawled on the sidewalk swilling a bottle of Woolite. 



slightly more upright. "I do not think 
you arc a doctor. I think you are a shoe 
salesman, and I do not need any shoes 
today, thank you." 

Although my patient was in the midst 
of an episode of mental illness, from 
which she soon recovered to display an 
intinitely sweet nature, that morning she 
nailed me neatly in front of a small but 
appreciative audience, none of whom 
laughed out loud. Too callow and embar 
rassed to do the right thing, I muttered 
something and strode off, as though I had 
a purpose. Only later did I realize what 
would have been the proper response: 
sit right down and have a good guffaw 
with her and our audience. 

But perhaps the most ridiculous I've 
ever felt as a physician was some 35 
years ago, at the beginning of my career, 
when I was supposed to be caring for an 
elderly woman who had entered the last 
days of her life. Mrs. Edel, as I'll call her, 
lay in a hospital bed, in considerable 
pain and barely able to move, but utter 
ly without complaint and with a con 
tinuing lively interest in the events 
around her. Her heart had reached the 
end of its useful life. Her circulation had 
slowed to the point that in places the 
blood was simply turning solid; her legs 



were so deprived of blood that they had 
become practically inert. 

For some insane reason, I believed it 
was my obligation to come to her bedside 
each day and ask her to wiggle her toes. 
Whenever I did this, she lay there unmov 
ing — because she couldn't move. Yet my 
neurology professors had often stressed 
the importance of motivating patients 
to do such things as touching their noses 
accurately, arm wrestling with me, or 
reciting the names of U.S. presidents. 
The motivational technique they impart 
ed, at least to me, was to shout. 

So I repeated my instruction several 
times, louder and louder: "Wiggle your 
toes, Mrs. Edel!" My telling her to do 
this was pointless, and if anything 
could be beyond pointless, it w T as my 
habit of shouting the command. On the 
next-to-last day of her life, as my voice 
rose once again, Mrs. Edel gazed up at 
me from her bed, and a positively imp 
ish smile came to her face. She looked 
me straight in the eye and said, with 
something just short of a titter, "By me, 
dat's viggling." ■ 

\\ 'illiam ha Bennett '6S, who practices psychiatry 
in Cambridge, Massachusetts, is editor-in-chief 
of the Harvard Medical Alumni Bulletin. 



AUTUMN 2004 • HARVARD MEDICAL ALUMNI BULLETIN 



31 






For decades now, 
'sicians have 
turned a clinical 
eye on small fry. 

f, then, does the 
epidemic persist? 



CHILDHOOD IS A SYNDROME THAT HAS ONLY RECENTLY 

begun to receive serious attention from clini 
phySICianS have cians. The syndrome itself, however, is not at 

all recent. As early as the eighth century, the Per- 
sian historian Kidnom made references to "short, 
noisy creatures" that may well have been what we 
now call "children." The treatment of childhood, 
Yvhy then ClOeS the however, was unknown until the twentieth cen- 
tury, when so-called child psychologists and child 
psychiatrists became common. 

Despite this history of clinical neglect, it has 
been estimated that well over half of all Ameri- 
cans alive today have experienced childhood 
directly (Seuss, 1990). In fact, the actual numbers 
are probably much higher, since these data are based on self-reports that may be subject Co 
social desirability biases and retrospective distortion. 

The growing acceptance of childhood as a distinct syndrome is reflected in its proposed 
inclusion in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, or DSM-V, 
slated for publication in 2010 by the American Psychiatric Association. Researchers are still 
in disagreement about the significant clinical features of childhood, but the DSM-V will 
almost certainly include the following core markers: congenital onset, dwarfism, emotional 
lability and immaturity, knowledge deficits, and legume anorexia. 



by Jordan W. Smoller 



» 



32 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 




are an "out-group. r Because of 
their intellectual handicap, they 
are even denied the right to vote, 



Clinical Features of Childhood 

Although this paper focuses on the effi- 
cacy of conventional treatment of child- 
hood, the five clinical markers mentioned 
above merit further discussion for those 
unfamiliar with this patient population. 

Congenital onset. In one of the few exist- 
ing literature reviews on childhood, 
Temple-Black (1982) has noted that child- 
hood is almost always present at birth, 
although it may go undetected for years 
or even remain subclinical indefinitely. As 
one psychologist has put it, "we may soon 
be in a position to distinguish organic 
childhood from functional childhood" 
(Rogers, 1979). 

Dwarfism. This is certainly the most 
familiar marker of childhood. It is widely 
known that children are physically short 
relative to the population at large. Indeed, 
common clinical wisdom suggests that 
the treatment of the so-called small child 
(or "tot") is particularly difficult. These 
children are known to exhibit infantile 
behavior and display a startling lack of 
insight (Tom and Jerry, 1967). 

Emotional lability and immaturity. This 
aspect of childhood is often the only basis 
for a clinician's diagnosis. As a result, 
many otherwise normal adults are mis- 
diagnosed as children and must suffer 
the stigma of being labeled as children 
by professionals and friends alike. 

Knowledge deficits. While many children 
have IQs at or even above the norm, 
almost all will manifest knowledge 
deficits. Anyone who has known a real 
child has experienced the frustration of 
trying to discuss any topic that requires 
some general knowledge. Children seem 
to have little understanding about the 
world they live in. Politics, art, and sci- 
ence — children are largely ignorant of 



these. Perhaps it is because of this igno- 
rance, but the sad fact is that most chil- 
dren have few friends who are not, them- 
selves, children. 

Legume anorexia. This last identifying 
feature is perhaps the most unexpected. 
Folk wisdom is supported by empirical 
observation — children will rarely eat 
their vegetables (Popeye, 1957). 

Causes of Childhood 



Now that we know what it is, what can 
we say about the causes of childhood? 
Recent years have seen a flurry of theory 
and speculation from several perspectives: 

Sociological model. Emile Durkheim was 
perhaps the first to speculate about 
the sociological causes of childhood. He 
points out two key observations about 
children: the vast majority are unem- 
ployed, and they represent one of the 
least educated segments of our society. In 
fact, it has been estimated that less than 
20 percent of children have had more 
than a fourth-grade education. 

Clearly children are an "out-group." 
Because of their intellectual handicap, they 
are even denied the right to vote. From the 
sociologist's perspective, treatment should 
be aimed at helping assimilate children 
into mainstream society. Unfortunately, 
some victims are so incapacitated by their 
childhood that they are simply not com- 
petent to work. One promising rehabil- 
itation program (Spanky and Alfalfa, 
1997) has trained victims of severe 
childhood to sell lemonade. 

Biological model. Again, the observation 
that childhood is usually present from 
birth has led some to speculate on a bio- 
logical contribution. An early investiga- 
tion by Flintstone and Jetson (1960) indi- 
cated that childhood runs in families. 



Their survey of more than 8,000 Ameri- 
can families revealed that over half 
contained more than one child. Further 
investigation revealed that even most 
non- child family members had experi- 
enced childhood at some point. 

Impressive evidence of a genetic com- 
ponent of childhood comes from a large- 
scale twin study by Brady and Partridge 
(1972). These authors studied more than 
106 pairs of twins, looking at concordance 
rates for childhood. Among identical or 
monozygotic twins, concordance was 
unusually high (0.92): when one twin 
was diagnosed with childhood, the other 
twin was almost always a child as well. 

Psychological models. Among the more 
familiar psychologically based theories of 
childhood is Seligman's "learned child- 
ishness" model, which holds that indi- 
viduals who are treated like children 
eventually give up and become children. 
As a counterpoint to such theories, some 
experts have claimed that childhood 
does not really exist. Szasz has called 
childhood an expedient label. In seeking 
conformity, we handicap those whom 
we find unruly or too short to deal with 
by labeling them children. 

Treatment of Childhood 



Efforts to treat childhood are as old as 
the syndrome itself. Only in modern 
times, however, have humane and 
systematic treatment protocols been 
applied. In part, this increased attention 
to the problem may be attributed to 
the sheer number of individuals suffer- 
ing from childhood. Government statis- 
tics reveal that more children are alive 
today than at any time in our history. To 
paraphrase P. T. Barnum: "There's a child 
born every minute." 



34 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 



The overwhelming number of chil 
dren has made government intervention 
inevitable. The nineteenth century saw 
the institution of what remains the 
largest single program for the treatment 
of childhood — public schools. Under 
this colossal program, individuals are 
placed into treatment groups based on 
the severity of their condition. For exam 
pie, those most severely afflicted may 
be placed in a "kindergarten" program. 
Patients at this level are typically short, 
unruly emotionally immature, and intel- 
lectually deficient. Therapy essentially 
becomes one of patient management and 
of helping the child master basic skills, 
such as finger- painting. Unfortunately, 
the school system has been largely inef- 
fective. Not only is the program a massive 
tax burden, but it has failed even to slow 
down the rising incidence of childhood. 

Faced with this failure and the growing 
epidemic of childhood, mental health pro- 
fessionals devoted increasing attention to 
the treatment of childhood. Given a theo- 
retical framework by Freud's landmark 
treatises on childhood, child psychiatrists 
and psychologists claimed great successes 
in their clinical interventions. 

By the 1950s, however, the clinicians' 
optimism had waned. Even after years 
of costly analysis, many victims remained 
children. The following case (taken from 
Gumbie and Pokey 1957) is typical. Billy J., 
age eight, was brought in tor treatment by 
his parents. Billy's affliction was painfully 
ob\ious. He stood only four- foot three and 
weighed a scant 70 pounds, despite his 
voracious eating habits. Billy presented a 
variety of troubling symptoms. His voice 
was noticeably high-pitched for a male. He 
displayed legume anorexia, and according 
to his parents, often refused to bathe. 



Billy's intellectual functioning was 
also below normal — he had little general 
knowledge and could barely write a 
structured sentence. Social skills were 
also deficient. He often spoke inappropri- 
ately and exhibited "wnining behavior." 
His parents reported that his condition 
had been present from birth. The diagno 
sis was "primary childhood." After years 
of painstaking treatment, Billy improved 
gradually. By age eleven, his height and 
weight had increased, his social skills had 
broadened, and he had become function- 
al enough to hold down a paper route. 

.After years of this kind of frustration, 
startling evidence has come to light 
suggesting that the prognosis in cases of 
childhood may not be all gloom. A criti- 
cal review by Fudd (1991) noted that 
studies of the childhood syndrome tend 
to lack careful follow-up. Acting on this 
observation, Moe, Larrie, and Kirly 
(1993) began a large-scale longitudinal 
study. These investigators studied two 
groups: one with 34 children currently 
engaged in a long-term conventional 
treatment program, the other with 42 
children receiving no treatment. All 
subjects had been diagnosed as children 
at least 4 years previously, with a mean 
duration of childhood of 6.4 years. 

At the end of one year, the results con- 
firmed the clinical wisdom that child 
hood is a refractory disorder — virtually 
all symptoms persisted and the treat 
ment group was only slightly better off 
than the controls. The results, however, 
of a careful ten-year follow-up were star- 
tling. The investigators (Moe, Larrie, 
Kirly, and Shemp, 2003) assessed the 
original cohort on a variety of measures. 
General knowledge and emotional matu 
rity were assessed with standard mea- 



sures. Height was assessed by the metric 
system (see Ruler, 1923), and legume 
appetite by the Vegetable Appetite Test 
(VAT) designed by Popeye (1968). Moe 
et al. found that subjects improved uni- 
formly on all measures; indeed, in most 
cases, the subjects appeared to be symp- 
tom-free. The researchers also reported a 
spontaneous remission rate of 95 percent, 
a finding that is certain to revolutionize 
the clinical approach to childhood. 

These results suggest that the prog 
nosis for victims of childhood may not 
be as bad as we have feared. We must not, 
however, become complacent. Despite its 
apparently high spontaneous remission 
rate, childhood remains one of the most 
serious and rapidly growing disorders 
facing mental health professionals today. 

Beyond the psychological pain it 
brings, childhood has recently been 
linked to a number of physical disorders. 
Twenty years ago, Howdi, Doodi, and 
Beauzeau (1984) demonstrated a six-fold 
increased risk of chickenpox, measles, 
and mumps among children as compared 
with normal controls. Later, Barby and 
Kenn (1989) linked childhood to an ele- 
vated risk of accidents — compared with 
normal adults, victims of childhood were 
much more likely to scrape their knees, 
lose their teeth, and fall off their bikes. 

Clearly, much more research is need- 
ed before we can give any real hope to 
the millions of victims wracked by this 
insidious disorder. ■ 

Jordan W. Smolkr VI, a psychiatrist at Massa- 
chusetts General Hospital and self proclaimed 
recovering child, penned this essay while a 
research assistant fresh out of college; although 
it has since been reprinted in several publica- 
t ions, we couldn't resist trotting out this excerpt. 



References 

Barby, B., and Kenn, K. (1989). The plasticity of 
behavior. In B. Barby and K. Kenn (Eds). 
Psychotherapies R' Us. Detroit: Ronco Press. 

Brady. C, and Partridge. S. (1972). My dad's bigger 
than your dad. Acta Eur. Age, 9, 123-126. 

Flintstone, F., and Jetson. G. (1960). Cognitive 
mediation of labor disputes. Industrial Psychology Today, 
2. 23-35. 

Fudd, E. J. (1991). Locus of control and shoe size- 
Journal of Footwear Psychology, 78, 345-356. 

Gumbie, G., and Pokey. P. (1957). A cognitive theory 
of iron smelting. Journal of Abnormal Metallurgy, 45 
235-239. 



Howdi, C . Doodi, C, and Beauzeau. C. (1984). 
Western civilization; A review of the literature 
Reader's Digest. 60, 23-25. 

Moe. R.. Lame, T., and Kirly, Q. (1993). State 
childhood vs. trait childhood. TV Guide, May 12-19, 1-3. 

Moe. R... Larrie, T.. Kirly, Q.. and Shemp, C. (2003). 
Spontaneous remission of childhood. In W. C. Fields 
(Ed.), New Hope for Children and Animals. Hollywood: 
Acme Press. 

Popeye. T. S. M. (1957). The use of spinach in extreme 
circumstances, journal of Vegetable Science 58, 530-538. 

Popeye, T. S. M. (1968). Spinach: A phenomenological 
perspective. Existential Botany. 35. 908-913. 

Rogers. F. (1979). Becoming My Neighbor. New York: 
Soft Press. 



Ruler, Y. (1923). Assessing measurement protocols by 
the multi-method multiple regression index for the 
psychometric analysis of factorial interaction. Annah 
of Boredom. 67, 1190-1260. 

Seuss, D. R. (1990). A psychometric analysis of green 
eggs with and without ham. Journal of Clinical Cuisine, 
245, 567-578. 

Spanky, D„ and Alfalfa, Q. (1997). Coping with 
puberty. Scars Catalog. 45-46. 

Temple- Black. S. (1982). Childhood: An ever- so sad 
disorder, Journal of Precocity. 3, 129-134. 

Tom, C, and Jerry. M. (1967). Human behavior as a 
model for understanding the rat. In M. de Sade (Ed), 
The Rewards of Punishment. Paris: Bench Press. 



AUTUMN 2004 • HARVARD MEDICAL ALUMNI BULLETIN 





Harvard Medical School alumni own up to clinical mishaps, slips 
of the lip, and other ludicrous moments in their professional lives 




Grave Error 



I had what we euphemistically termed a Difficult Patient. I was an intern, 
and I had done everything I could to make the elderly man comfortable. 
Though bedridden with pneumonia, he was not too weak to criticize 
my every effort. Staggering with exhaustion at the end of working 36 hours 
straight, I nonetheless steeled myself to check in on him one last time. As I 
was leaving his bedside, I cheerily and unthinkingly advised, much to his 
outrage, "Rest in peace!" 

— ELIZABETH MILLER '92, CAMBRIDGE, MASSACHUSETTS 



36 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 




Late Bl 



oomer 



My patient walked in, a quiet, dignified 
lady in a long, rustling, black taffeta dress. 
She had seen me several times before yet 
always maintained a reserve. Despite my 
efforts to put her at ease, she rarely offered 
even a fleeting smile. 

I needed to check her liver edge for 
possible hepatitis. The nurse helped her 
onto my new examining table, complete 
with seven levers on its hydraulic base to 
provide endless combinations of positions 
and elevations. I pumped the table up 
high — indeed, too high, so I touched the 
release lever to lower my patient. But I had 
pressed the wrong lever. 

As the entire head of the table sank to 
the floor, the patient's body began a slow 
slide, at which she started kicking the air, 
revealing two full white petticoats atop 
long white bloomers. The dazzling display 
reminded me of an inverted cancan dancer. 
She slid completely to the floor behind the 
table, then burst into gales of laughter, 
which continued until we helped her to 
her feet. She stood flushed and radiant. 

Thereafter she was one of my most 
congenial patients. 

— DONALD BICKLEY '34, 
WATERLOO, IOWA 



The Naked Truth 

I first met my new lab partner over the discard barrel as he cheerfully dispatched 
his latest experiment-gone-bad with a fire extinguisher. We were taking organic 
chemistry in the summer of 1952, and I feared that the "killer" course might 
prove literally fatal in his case. Fortunately, he survived to become one of the best 
psychoanalysts in the world — but not before a particularly memorable mishap. 

Late one afternoon, my partner bumped against a flask of nitric acid he kept 
stored on his laboratory bench. When the flask struck the granite counter, corrosive 
acid splattered all over the handsome seersucker suit he had donned in anticipation 
of a cocktail party that evening. A few holes immediately appeared in the suit — and 
they seemed to be enlarging by the second. 

My friend sprinted for the door, bolted down the stairs, and hopped on his bike 
to make a desperate dash for home. But he was too late. By the time he reached 
Harvard Square, his suit and shirt had disintegrated. He was Harvard's first streak- 
er, peddling frantically through the startled commuter crowd wearing nothing but 
sneakers and briefs. 

To this day he is convinced he is a better analyst because he has actually experi- 
enced the classic nightmare of being naked and defenseless in a large crowd. 

— ANTHONY PATTON '58, DANVERS, MASSACHUSETTS 







t 




AUTUMN 2004 • HARVARD MEDICAL ALUMNI BULLETIN 37 




In a Snit 

A nursing shortage in the late 1970s 
led my surgical practice to recruit 
and train some staff from the Philip 
pines. Technically they excelled, but 
occasionally the language gap creat- 
ed misunderstandings. 

One of my favorite partners in 
the practice wasn't afraid to cuss 
when events turned sour in the 
operating room. In the midst of a 
large abdominal aortic aneurysm 
resection, he nicked an anomalous 
branch of the patient's vena cava, 
and blood began spurting from a 
small, almost invisible hole. As a 
resident called for help, I could hear 
my partner yelling, "Shit! Shit! Shit!" 
For every "Shit!" he spat out, his 
Filipino nurse handed him a snit, a 
special clamp we used in thoracic 
and vascular surgery. 

When I arrived just seconds later, I grasped the severity of the problem in a glance: 15 snits were lined up, ready for use. 

— ANTHONY PATTON '58, DANVERS, MASSACHUSETTS 



The Da Vinci Code 



When I was a first-year psychiatry resident at McLean Hospital, during the Christmas crush of admissions I was called to 
evaluate a middle-aged Italian bricklayer. According to the chart, he had experienced several recent episodes of violence, 
attacking his brother, his father, and his dog, a cockapoo named Moose — short for Mussolini. His chief complaint: "I am God." 
I asked a security guard to come into the interview room with me. The patient — call him Primo — was a short, fat, laser-eyed man dressed 

all in black. He was sweating profusely even though it was freezing outside and cold 
in the room. 

"How do you know you're God?" I asked. 
"Because I was chosen." 
"Why were you chosen to be God?" 

"Because I was in hell. You want proof?" He lifted up his shirt. On his belly was 
a magnificent tattoo of The Last Supper. Clearly it had been done many years before, 
when he'd been thinner and what was now his belly had been his chest, for the tattoo 
had expanded, so that Christ and the Apostles were all wearing broad grins. 
"What'd you think, Doc?" the security guard said after we'd locked Primo up. 
"298.80. Brief reactive psychosis." 
"You don't think he's God?" 
"He may well be," I said, "but it's not reimbursable." 

— STEPHEN BERGMAN '73, NEWTON, MASSACHUSETTS 




HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 



A Wrenching Discovery 

I had just started my internship when I was assigned to take a blood specimen to 
the Thorndike Laboratory at the Boston City Hospital for testing. Upon arrival, 
though, I found the laboratory deserted. Finally I heard the sound of pipes 
clanging and noticed a pair of legs jutting out from under a sink. I gently kicked the 
legs a few times and said, "Hey, buddy, how can I find someone who works here?" The 
legs inched themselves out, a trunk and arms followed, then a face, and, by God, I 
found myself staring at the famous chief of medicine himself, William Castle '21 . 
I flushed with mortification, but Dr. Castle didn't seem to mind. He politely took the 
tube of blood from my trembling hand, filled in the correct information, thanked me, 

and slid under the sink again. 

— ROBERT COTSEN '56, BUFFALO, NEW YORK 





During my internship at the Boston 
City Hospital, a man was brought to 
our emergency department apparently 
in a coma. It didn't seem like the usual 
coma, though. 

Our rude attempts to rouse him 
failed, but a catheter produced normal 
urine. A lumbar puncture was under 
way when he slowly began to awaken. 
Then, startled at our ministrations, he 
tried to sit up, claiming to be a cardiol 
ogist. We greeted his declaration with 
guffaws of disbelief until he accurately 
described the electrocardiogram of 
Wenckebach's phenomenon. 

A graduate student, he had taken 
a sedative to help him sleep. He had 
been watching television in the lobby 
of his rooming house while waiting 
for the pill to take effect when, woe 
to him, he had fallen so deeply asleep 
that his landlady had called an ambu- 
lance. He was less than grateful for 
our care. 

— STANLEY VAN DEN NOORT '54, 
TUSTIN, CALIFORNIA 



AUTUMN 2004 ■ HARVARD MEDICAL ALUMNI BULLETIN 



39 







- ' — *~- ->^.t»»^— ,« ■ -». -..^ -- -^-. 



HARVARD MEDICAL ALUMNI BULLETIN -.AUTUMN 2004 



.•^■■ItfSk *Jm* 







fe£ 




richly eccentric cast of characters whose lessons are not easily forgotten, by PlETER KARK 






ATE ONE SULTRY SPRING EVENING IN 1966, I WAS 

sitting in a ward laboratory at the Boston City 
Hospital sipping coffee with several student nurs- 
es and Tom, my fellow intern. Suddenly, a burly 
cop exploded into the room, one hand gripping his 
holstered gun, the other his nightstick. "Where is 
she?" he yelled. "What have you been doing to 
her?" Tom and I jumped and turned pale. Our 
minds raced with the fear and vague guilt a police 
officer's mere presence can inspire in young men. 



Slowly we realized the source of the cop's 
agitation. Tom had just finished examin- 
ing a deaf, demented, and exceedingly frail 
elderly patient. She suffered from painful 
arthritis in her major joints and had 
screamed throughout the process. The 
cop had heard the shrieking while 
patrolling the street below. Aware that 
student nurses were often alone on the 
wards at night, he had stormed the hospi- 
tal: first the nurses' dormitory, then the 
surgical block, then the other two medical 
buildings, and now, floor by floor, ward by 



ward, he was scouring our building. By 
the time he reached us, Tom's patient had 
dozed off and quiet had descended. 

Fortunately one of the student nurs- 
es happened to be the cop's niece twice 
removed, and, after a half hour of sooth 
ing talk and several cups of tea, she 
finally convinced her uncle all was well. 
But Tom and I were startled to realize 
that after two years of working in the 
busy charity hospital, we had become 
so accustomed to patients' screams that 
we no longer even noticed them. 



Unconventional Wisdom 

I still consider the Boston City Hospital 
to be my hospital. Although nearly four 
decades have passed since my time there 
as a fourth-year medical student and then 
a house officer, its lessons return with 
every difficult case, diagnostic problem, 
and ethical dilemma I encounter. 

The hospital as I knew it no longer 
exists; Boston University took over the 
buildings and institution 20 years ago 
and has since changed the name to 
Boston Medical Center. The hospital of 
40 years ago, by contrast, was a mongrel. 
Like Gaul, its faculty was dmded into 
three parts: the medical schools of Har- 
vard, Tufts, and Boston University. Each 
school ran two medical services, one or 
two surgical services, and one or two 
specialty services. 

The hospital's ten buildings, some of 
which dated to the time of the Civil War, 
had fallen into severe disrepair. The walls 
had faded to an indeterminate gray. The 
floors were covered with flimsy sheets of 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 



J III ▼If ▼ 1 showed up after the Cocoanut Grove 
nightclub fire and volunteered for the next several decades. 



linoleum, by my time so cracked and peel 
ing that the blackened original wooden 
floorboards showed through. The ceil- 
ings of Peabody, the building housing 
Harvard's Second Medical Service, had 
been built 20 feet high to minimize cross- 
contagion by microbes. With only one 
working bulb in every other fixture, at 
night the Peabody ward became a dark, 
shadowy cavern of indefinite height. 

The mingled scents of decay, harsh 
disinfectant, exhaled alcohol, and stale 
cigarette smoke pervaded the hospital. 
The sickly aromas emanating from large 
vats of rancid peanut butter and grape 
jelly permeated the ward kitchens no 
matter what was cooking. And the lab- 
oratories smelled of the chemicals and acters 



dyes we house officers used to analyze 
blood, urine, spinal fluid, bone mar 
row, sputum, and pus. 

Although the facilities were 
decrepit and the atmosphere fetid, 
the physicians who worked at the 
Boston City Hospital sparkled as 
some of the finest in the world. Dur 
ing much of the twentieth century 
the Harvard services produced half 
the chairmen of medicine and surgery 
tor the rest ol the country. The house- 
staff, from whose ranks those chair- 
men would emerge, were also out- 
standing. But what helped make the 
Boston City Hospital's lessons so 
vivid tor me were the colorful char- 
not onlv the doctors, nurses. 



'-*¥' 



»v 



\ 



>~ 



BOSTON'S BUSY HOSPITAL: Above left, an early operating theater at the Boston City 
Hospital; above, hospital staff collecting medications; top right, researchers working in 
the hospital's Thorndike Memorial Laboratory. 



and residents, but also the volunteers 
and patients. 

Jimmy was an unpaid volunteer of 
mysterious origins. Some say he first 
showed up on "Medical 5" — the male 
ward of the Fourth Harvard Medical Ser 
vice — after the city's infamous Cocoanut 
Grove nightclub fire in 1942. He arrived 
to help out every weekday evening for 
the next several decades. 

Jimmy was articulate and cultured. 
He carried a wad of big bills stuffed in 
his back pocket, but never revealed his 
full identity, background, or reason for 
volunteering all those years. If the senior 
faculty knew the truth about Jimmy, they 
never told us. Generations of Harvard 
medical house officers speculated that 
his true love had died in the Cocoanut 
Grove inferno. All we knew for sure was 
that he disappeared at midnight and 
reappeared by five the next evening. 

Jimmy had worked closely with hun 
dreds of house officers over the years. 
When we missed difficult diagnoses, 
he would console us by telling us how 
a certain professor, now the distin 
guished author of a textbook on the 
subject, had missed the diagnosis in just 



AUTUMN 2004 • HARVARD MEDICAL ALUMNI BULLETIN 



^^C^^lxV7C usually sat still, with an occasional 
jerk, but if the spirit moved him he could suddenly sprint away. 



such a case 15 years ago while serving as 
an assistant resident. 

During his decades at the hospital, 
Jimmy had not only learned a great deal 
about medicine, but had also developed 
practical techniques the likes of which 
we were never taught at Harvard Med 
ical School. When psychotic patients 
attacked us with carving knives, he 
would grab a trashcan lid to use as a 
shield until he could subdue the attacker. 
Then he would pin the miscreant in a 
bear hug and calmly recommend which 
medicine we should inject in the 
patient's posterior, usually paraldehyde 
or Thorazine. With Jimmy around, we 
never needed to call the cops. 

Jimmy also had a knack for restraining 
the most rambunctious drunk or patient 
with delirium tremens for a spinal tap. In 
fact, it was Jimmy who taught us interns 
to do taps properly My first one was on 
a man whose DTs had just started. Jimmy 
showed my fellow intern how to hold the 
patient in the fetal position, as a wrestler 
might. I knelt on the floor to the bed's 
left, the sterile spinal-tap tray with all its 
gear on a rolling table between Jimmy 
and me. Jimmy poured iodinated disin- 
fectant into one small steel cup on the 
tray and Novocain into another and 
talked me through the tap, step by step. 

We began the procedure in the far- 
thest left of a row of six empty beds and 
somehow completed the tap in the far- 
thest right-hand bed — just before the 
patient tried to shove my fellow intern 
through the window. How — especially 
with me keeping my gloved hands high 
in the air to avoid contaminating them — 
had we all managed to struggle across 
those three foot- wide spaces between 
the beds? 

The Madness of King George 

One professor about whom Jimmy 
could never report a missed diagnosis 
was Derek Denny Brown. Many experts 
consider Denny- Brown to have been one 




HARVARD MEDICAL ALUMNI BULLETIN ■ AUTUMN 2004 




George didn't remember who — let 
alone where — he was. He couldn't 
recall the name of the cardinal of 
Boston, the last question we posed in 
our standard amnesia tests. He was 
incapable of giving us a history, the 
key to most diagnoses, especially of 
diseases of the brain. He also exhibit- 
ed a number of bizarre reflexes, each 
hinting at damage to the frontal cor- 
tex or between the frontal lobes and 
the midbrain. If I poked a pencil or a 
tongue-blade toward his mouth, his 
lips would purse like those of an 
infant preparing to suckle. If I stroked 



least three generations, and list the 
patient's homes and jobs throughout his 
life. We were required to find out his 
hobbies; his habits, especially the bad 
ones; his allergies; his medicines during 
the past decade; and his history of hospi- 
tal admissions, because any one of these 
might hold the key to his diagnosis. 

We also needed to have examined 
every organ of the patient's body and the 
20 subsystems that comprised the ner- 
vous system. We plotted the visual fields 
and sensory difficulties in minute detail 
on special graphs. We charted results of 
pertinent laboratory work and x-rays. If 



of the best clinical neurologists and 
neurological investigators of the twenti- 
eth century. His rate of correct diag 
noses was 75 percent at a time when 
many other neurologists were happy to 
achieve 50 percent, and he had discov- 
ered one-quarter to one-half of the neu- 
rological diagnoses then known. 

Denny-Brown was tall and handsome, 
a New Zealander who had made his 
mark in Oxford and London before 
coming to Harvard and the Boston City 
Hospital, where he became chairman of 
neurology. He arrived early in World 
War II wearing his crisp British Army 
uniform, and the women at the hospital 
reportedly swooned on sight. The men 
simply held him in terrified awe. With 
his immense knowledge, he was justifi- 
ably haughty. While he could be kind 
and compassionate, he did not suffer 
fools gladly. He wouldn't hesitate to pub 
licly humiliate a resident who was illogi- 
cal or ignorant of a critical fact. 

Twice a week, Denny-Brown conduct- 
ed formal teaching rounds, famous for 
their ceremony and precision — he liter- 
ally went from bed to bed to teach the 
lessons each patient held for us. When 
I rotated to Denny-Brown's neurology 
service, I brought with me a patient who 
was clearly demented, but before pre- 
senting him to the master, I needed to 
determine what kind of dementia he had. 

George was a short, broad-shoul- 
dered man in his early fifties, with a 
dull, blank face. His stubbly cheeks 
puffed out below darting eyes. He usu- 
ally sat still, with an occasional jerk, 
but if the spirit moved him he could 
suddenly sprint away. 





1 *■ 


^^m Air' ifl 


■ 






\ smW 


/v 1 " 






dBr*^ 





J. 



WIZARDS OF ODDS: Left, surgeons operating in the Sears Surgical Laboratory at the 
Boston City Hospital in 1 967; top left, Derek Denny-Brown ran the neurology service with 
ferocious dedication; above, doctors in the heart catheterization section of the hospi- 
tal's Thorndike Memorial Laboratory evaluate a patient's fitness for surgery. 



his hand from his wrist toward his fin- 
gers, his digits would grasp mine tightly, 
hold on all the more tightly the harder 
I tried to pull away, and release me only 
when I stroked the back of his fingers 
in the opposite direction. 

That first Tuesday's rounds were too 
early for us to present George to Denny- 
Brown because it took several days to 
work a patient up to Denny-Brown's 
exacting standards. We had to capture 
the history of the illness with detail and 
precision, trace the family history back at 



the patient had a mental problem, we 
administered a three-hour-long mental 
status examination, one hour at a time 
because, we were taught, no patient 
could keep awake and concentrate for 
a longer stretch of time. 

After the intern or assistant resident 
had performed all these tasks, the neu- 
rology chief checked the key points inde- 
pendently, and then the entire ward team 
re-evaluated the case for an hour, follow 
ing the history and examination con 
ducted by the attending faculty member. 



AUTUMN 2004 • HARVARD MEDICAL ALUMNI BULLETIN 



For the lirst week, before we had done 
an exhaustive workup on George, the 
neurology chief resident instructed me 
to hide George in the elevator during 
rounds. For those three hours, George 
rode up and down with the elevator man 
so Denny-Brown wouldn't know he was 
on the ward, wouldn't become enraged, 
and wouldn't hurl the nearest steel- 
bound patient chart across the room 
and through a windowpane. 

Keeping George under wraps for a 
entire week presented a formidable 
challenge, as George, like many of our 
patients with dementia, tended to wan- 
der. A large sign posted on the door to 
the stairs helped: "George, do not go 
here. The Sphinx will get you." The sign 
on his back asking that he be returned to 
our ward also proved effective. 

Once, while a few of us were working 
up a new patient, we heard cries for 
help from George's room down the cor- 
ridor. They came from the patient in the 
next bed. Using sheets to avoid hurting 
him, we had tied George into an arm- 
chair so that he could sit in the hall and 
enjoy the bustle. Thwarted in his efforts 
to untie the knots, he had humped the 
chair backward to his bedside table, 
manipulated the drawer open with 
what little flexibility his bound wrists 
allowed him, and retrieved a book of 
matches. As we ran into the room we 
found him trying to free himself by 
igniting the sheets. 

The next Tuesday, at formal rounds, 
George helped reveal his own diagnosis. 
Promptly at ten that morning we all 
assembled in the large room at the west 
end of the ward's corridor, a semicircu- 
lar room containing 20 beds. The partic- 
ipants included faculty members, neu- 
rologists in private practice and from 
other hospitals, a full complement of 
residents and interns, and all the third- 
and fourth-year medical students 
assigned to the neurology rotation. The 
neurology chief resident stood by the 
first bed, holding a white tray with the 
various tools so dear to neurologists: 
pins, cotton, tuning forks of various 
sizes, an ophthalmoscope, a flat piece of 
red glass, and a reflex hammer. 

Five minutes passed. We all looked at 
each other in bewilderment; from the 
first day he had walked into the Boston 
City Hospital, Denny-Brown had never 
been late for rounds. Another five min 



utes went by before a glowering Denny 
Brown finally arrived. But where was 
his coat? He always wore a long, pristine 
white lab coat when presiding over the 
wards; the rest of us resembled waiters in 
our short white jackets. 

No one dared speak a word. Denny- 
Brown nodded his head in the tradition- 
al signal, and the chief resident presented 
a thumbnail sketch of the first patient's 
problem. Denny-Brown picked up the 
flat piece of red glass from the tray, 
demonstrated the single most critical 
neurological sign — in this case a rare 
kind of double vision — and eloquently 
explained why that patient had that 
form of that particular variant of Fried- 
reich's ataxia. Then the flock of 15 or 20 
of us sidled to the next bed. 

Again, the chief resident summarized 
the case and Denny- Brown reached for 
the tray. Just then an apparition broke 
through the encircled audience: a short 
man with heavy beard stubble, clad in 
a long white robe that trailed past his 
ankles to the floor behind him. The 
ghostly figure snatched the reflex ham- 
mer from the tray, neatly tapped the 
patient on the left knee, flung the ham- 
mer across the room, then dashed down 
the hall. Denny-Brown dropped his arm 
and stood like the rest of us, slack 
jawed and dumbstruck, staring after the 
vanishing apparition in the long white 
gown, whose tails flowed behind him 
like the train of a runaway bride. 

It was George, of course. He had 
stolen Denny-Brown's coat and skulked 
behind us until he spied an opening. 
Those mortified few of us not trying to 
tackle George before he reached the 
stairs had to present his case then and 
there to Denny- Brown. 

"Aha — dementia at so early an age!" 
Denny-Brown exclaimed. "And clear 
megalomania — imitating mc at the bed- 
side in my laboratory coat! Obviously, 
general paresis of the insane. How many 
lymphocytes in the spinal fluid? Six or 
eight — well, there you are — I thought so, 
thank you. It can be nothing else. Give 
him a course of penicillin, and find him a 
bed at the chronic disease hospital in the 
harbor. Next case." 

General paresis of the insane is the 
form of brain syphilis that some later 
theorized could explain the megaloma 
nia of several famous but failed dictators 
in small countries around the world. 



Pants on Fire 

In addition to formal rounds with an 
attending such as Denny Brown, we 
assistant residents went to morning 
report with Charles Da\idson, associate 
director of the Harvard Medical Services, 
promptly at eight, just after receiving our 
individual ward's report from the night 
float and regular interns. Over coffee and 
doughnuts, we discussed who had been 
admitted, who had died, and what prob- 
lems had arisen overnight. 

Charlie was a marvelous teacher, kind 
and astute. He was also a dapper dresser, 
and when he appeared one morning look- 
ing disheveled, we clamored to know why. 

"Oh, this," he said, raking his fingers 
through his hair and adjusting his tie. 
"Well, I was walking through the snow 
from the parking lot when I saw a naked 
man jump down from the second floor 
fire escape of the Medical Building. A 
student nurse was chasing him. I knew 
he had to be one of our patients, so I 
tackled him in a snow bank and the 
nurse and I hauled him back to his ward." 
The naked man, diagnosed with both 




FROM THE HEART: Above, Charles Davidson, 
who oversaw the Harvard training pro- 
grams, was a beloved mentor; right, 
equipment used in the 1 960s to monitor car- 
diovascular data in the laboratory of Walter 
Abelmann, now professor emeritus at HMS. 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 



A\ ^r II^JH ^1 posted on the door to the stairs 
helped: "George, do not go here. The Sphinx will get you." 




dementia and delirium tremens — it took 
both diseases to provoke so desperate a 
flight — belonged to my team, of course. 

Another memorable patient. Jack, 
didn't have dementia, but he often mim- 
icked the DTs, because he knew we 
would administer paraldehyde, an ideal 
drug in many ways: it can be given by 
any route, leaves the body solely through 
the lungs, and can be tolerated by 
patients with liver or kidney disease. Its 
disadvantage is its horrible odor, like 
that of a sickly-sweet nail polish 
remover, a smell that can linger for days 
after a patient receives a single dose. 

Despite its noxious smell, we revered 
paraldehyde for another reason: alco- 
holics are often susceptible to other 
addictions besides alcohol, and unlike 
the other drugs administered for the DTs 
at that time, paraldehyde didn't seem to 
be habit forming. Until Jack came along. 

A short, squat man, Jack eagerly 
abused any substance available. He 
knew, for example, that the purple dye 
used to color the rubbing alcohol on the 
ward would make him sick, as it was 
designed to do. But it wouldn't kill him, 



so he downed the stuff anyway. And he 
was always smuggling in one drug or 
another in one orifice or another. 

Jack showed up on our ward two or 
three times each winter. We never had 
any choice but to discharge him to a 
nursing home or a chronic disease hos- 
pital. But his personality was so repel 
lent, his cracks about the other patients 
so nasty, and his compulsions to fondle 
and steal their clothes and belongings 
so unnerving that every nursing home 
and chronic disease facility within a 25- 
mile radius of the Boston City Hospital 
had declared him persona non grata. 

Jack knew how to manipulate the 
system all too well. The three medical 
schools' services rotated shifts for emer- 
gency room call, and Jack knew when it 
was Boston University or Tufts, rather 
than Harvard, on the ER. He would 
come in, in the cold of winter, reeking of 
alcohol he had just stolen. To be admit- 
ted and administered his beloved par 
aldehyde, he would convincingly mimic 
a liver flap — a repeated jerk of both 
hands from the wrists when the arms 
and hands are fully extended — a move- 



ment that usually signals that the liver 
is not clearing toxins from the blood. 

The other services didn't know Jack 
like we knew him. They would admit 
him, place him on the Danger List, and 
assign him to my service, to which he 
belonged because he had first been admit 
ted to us 10 or 15 years earlier. Hospital 
regulations about the Danger List man- 
dated that we retrieve him, work him 
up, and keep him for at least 72 hours. 

Up on the ward, Jack would work his 
usual mischief, but not until the smell of 
paraldehyde had invaded the floor and 
sent him into a delightful oblivion. By the 
time the resident came for morning 
rounds, Jack had entered Elysium, where 
he would stay for another 12 hours until 
the paraldehyde wore off. Because Jack 
didn't have the DTs, he didn't have the 
usual DTer's stimulation of the brain to 
counter the effects of paraldehyde. Once 
the drug wore off, and we refused to give 
him more, he would make outrageous 
demands for alcohol, tranquilizers, some- 
one else's watch, cane, or portable radio, in 
a loud, querulous voice, up and down the 
hall, throughout the ward, day and night. 

By the third day of Jack's ruckus, the 
year I served as assistant resident, it 
was clearly time to discharge him; the 
interns and nurses would have quit if 
I hadn't. The temperature outside had 
dipped below zero and the snowdrifts 
were high. Jack took off all his clothes, 
piled them in the middle of the 20-bed 
room, and set them on fire. He stood 
naked beside the pyre, legs planted 
apart like a football blocker, hands on 
his hips, a triumphant smile on his lips, 
and the gleam of victory in his eyes. 
Now he couldn't be discharged. 

Every patient in that room immedi- 
ately donated an article of clothing to 
get him out. ■ 

Fitter Kark '65 recently closed his private 
practice in neurology to take up a fellowship 
in palliative care, an area of medicine he loves 
to teach. 



AUTUMN 2004 • HARVARD MEDICAL ALUMNI BULLETIN 




48 HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 



■ 




THAT BIND 

The reluctant decision to set aside his 

scalpel for good prompts a surgeon to reflect on 

decades of dedication to his art 



The nurse relayed the mother's questions to me: 

Would her son awaken in the middle of the operation? Would he feel any- 
thing? How much would he temember afterward? These queries were ones 
I had answered coundess times, my replies always a blend of medical objec- 
tivity and sympathy. ■ Then the nurse paused. "The mother had another 
question," she said, smiling mischievously and closing the folder. "She 
asked, 'What if the surgeon should drop dead while he's operating on my 
son? After all, he is getting long in the tooth.'" ■ The nurse had found the 
question funny, but for me it raised disquieting thoughts. The mother was, 
of course, on to something. At 72, 1 wasn't senile but I also wasn't as vigor- 
ous as I had been ten years earlier. After a six-hour operation I found myself 
more exhausted than jubilant. No child in my care had ever died because 

by Ken Kenigsberg 



AUTUMN 2004 • HARVARD MEDICAL ALUMNI BULLETIN 



49 



DURING 



the next few years, tying a non-slipping 




of my infirmities, at least not yet — and 
I wanted to keep it that way. 

And then there was the advice we 
surgeons shared among ourselves: Get 
out while your colleagues still ask, 
"Why now?" instead of, "Why not 
before?" We all knew surgeons who had 
stubbornly continued to operate past 
their prime. And I could still remember 
the mordant warning of Francis Moore 
'39, one of my surgery professors at Har- 
vard Medical School, "Never let a 70- 
year-old man holding a sharp instru- 
ment get close to you!" 

The concerned mother's question 
wasn't the only yellow light flashing. I 
was finding it harder to get up at three 
in the morning to attend to a sick child — 
and the visit always left me in an irascible 
fog that persisted through the next 
workday The physical changes that had 
come as a natural part of aging were 
accompanied by other challenges — over 
time, the medical profession itself had 
changed. Dealing with severely compro- 
mised newborns had become a searing 
ethical problem without any satisfactory 
solution. And the increasingly adver 
sarial nature of the health care system 
was undermining the previously warm 
and trusting relationship between the 
family of a sick child and the physician. 

So it was just three months later that I 
closed my office door for the last time. At 
first I was distracted by everything I need- 
ed to do: return my beeper, notify parents 
and referring pediatricians, terminate my 
insurance, say goodbye to my secretary 
who, until those final tears, had always 
been a warm and smiling presence. 

In my scurry to bring to a close 
40 years of surgical practice, I didn't 
appreciate the momentousness of my 
life change until one morning a week 
later, when I stooped to tie my shoe. I 
made one loop in the lace and instinc 
tively coiled it loosely to keep the knot 
from slipping. Unbidden, my fingers 



reminded me of the first time I had tied 
a knot that way. The exercise had been 
part of a drama staged in the dog 
surgery laboratory during my first year 
of medical school. 

On the first day, the surgical instruc 
tor told our fledgling group that bacteria 
could cause an infection if transferred 
from our hands to an operative site and 
therefore we had to exorcise the little 
demons from our hands and arms. To 
gain a realistic appreciation of the prob- 
lem, we painted our hands and arms 
with a slurry of lamp black and corn oil. 
Then we were given a hard wooden 
scrub brush, positioned in front of a sink 
with running water, and told to scrub 
our hands and arms clean. Because the 
foul concoction represented invisible 
microbes, we were blindfolded to simu- 
late our scrubbing off unseen bacteria. 

After an interminable search- and- 
scrub mission conducted in deepest 
darkness as we tried to map the topogra- 
phy of our upper extremities, our blind- 
folds were removed. When I could see 
again I was dismayed to find that the 
pungent gunk had been catapulted from 
our scraped and bleeding arms to our 
faces by the steel-spring-like bristles 
of the brushes. Only our shielded eyes 
revealed our original colors. Strangely, 
even though so much of the slimy mess 
was now on our faces, our hands and 
arms seemed as covered as before. 

Having been introduced to the black 
stuff, we began to find out about the 
real surgical thing, the red stuff. "Are 
you going to just stand there while that 
poor dog bleeds to death," our instruc- 
tor bellowed, "or are you going to tie off 
that vessel?" We had to pick up a tool 
that looked like a cross between scis- 
sors and pliers, plunge it into a puddle 
of blood that presumably had a leaking 
vessel at its base, and tie string around 
the whole mess. That's when my trouble 
with tying started. 



To avoid the wrath of our instructor, 
Carl Walter '32, we had to tie the vessel 
off just right. I had to lay the first pass of 
the knot flat, make a second loop with 
out disturbing the first, then follow the 
first pass with a second one to secure and 
complete the knot. It seemed so simple, 
just a knot. And yet so many pitfalls lay 
before me! Too much tension, and the 
thin suture would break. A pull in the 
wrong direction, and it would skid off 
the vessel. A little jiggling of my hand, 
and the knot would fall apart, allowing 
the blood leaking from the vessel to flow- 
in to a red floodplain. To avoid such a dis- 
aster, for hours I practiced tying a piece 
of string to my bedpost. Finally I had it: I 
could tie a perfect knot blindfolded. 

I used a non-slipping knot on a patient 
for the first time when I was a student 
and a resident let me excise a sebaceous 
cyst under his supervision. During the 
next few years, tying a non-slipping knot 
became as automatic as breathing, and 
for 50 years thereafter I tied the knots in 
operations great and small, on newborns 
and on war wounded men. 

It was a non-slipping knot that saved 
me — and my patient — during one of the 
most anxious episodes of my surgical 
career. The patient was a two-week 
old infant. I had just divided a patent 
ductus arteriosus — a dangerous congen 
ital connection between the aorta and 
the pulmonary artery — and was in the 
process of closing off the two ends. 

During this tricky procedure, my 
chief, Robert Gross '31 — who also hap- 
pened to have become famous as the first 
person to perform this operation — was 
watching me. He had not planned to par- 
ticipate in the surgery and so had not 
scrubbed in. I put in a single stitch, but 
before I could tie it down, the aorta 
began to bleed, and the patient's tiny 
chest cavity began filling with blood. 

Gross spoke for the first time. "Don't 
break it," he murmured. I tied the knot 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 



knot became as automatic as breathing. 




and prayed. The bleeding stopped — and 
the baby boy was saved. 

In many ways, the hands tying a sim- 
ple surgical knot reveal their character. 
If those hands have carried out many pre- 
vious operations, they tie knots quickly, 
slickly, automatically. The knot is like a 
secret handshake; one surgeon recog- 
nizes another by the ease with which a 
knot is tied. He can tell where the opera- 
tor was trained by the suture he uses and 
whether he employs the classic two-hand 
knot or the more expeditious one-hander. 

Such skill is critical, lor mines lie 
hidden in the unexplored territory of the 
operative site. When the surgeon stum 
bles into a large arterv or vein, blood 




erupts, producing an immediate threat 
to the life oi the patient and a sudden 
upwelling of terror for the surgeon, as if 
his life, too, were at risk. His desperation 
transmits to the other members of the 
surgical team as if by telepathy. The anes- 
thesiologist's head materializes above 
the screen, the assistant tenses torward. 

Usually the flow is arrested. But 
before the surgeon faces the family, he- 
must erase all traces of consternation 
about the near tragedy. He removes his 
spattered mask, regains his composure, 
and strides into the waiting room. Some 
have likened the surgeon in this moment 
to a swan: smooth as silk above and kick 
ing furiously below 

The operating theater is the site of 
the ultimate reality play. Vs the body is 
opened and the curtain drawn back from 
what lies within, the plot is revealed. 
The preoperative diagnosis, even with 
all the modern aids, is still presumptive. 
For the surgeon — like the necromancer 
of old — the newly revealed organs hint 
at the patient's fate. Following the open 
ing revelatory scene comes the operation 
11 sell Here, the surgeon's skill and expe- 
rience assume primacy. 

As he plays his role, the operator 
loses awareness ol events outside the 
dazzlingly lit stage, including his own 
physiology. The patient on the table is 
unconscious; the surgeon at her side is 
unconscious of all but the patient. The 
operation becomes an arena of concen- 
tration with other considerations hid 
den behind an impenetrable curtain. 

The surgeon's commitment to his craft 
always wins out. Social obligations, 
birthdays, the beloved tennis game are 
pushed aside in deference to the operat- 
ing room. The spouse, the child, the 
tennis partner accept the priority of the 
surgical summons. The surgeon may feel 
some bitterness that only he among his 
friends is subject to having his life inter- 
rupted by confounded calls to duty. His 



accountant doesn't get up at two in the 
morning to calculate taxes, and his 
neighbor, the lawyer, is kept from his 
golf date only by rain. Neither accoun- 
tant nor lawyer feels the onus of being 
directly responsible for a life. 

Yet the compensation is enormous. 
The irresistible compulsion of the sur- 
geon's vocation provides clarity to his 
life. His duty is sharply defined and 
irrefutable, not only to his patient but 
to society as a whole. By carrying out the 
inconveniently timed operation, he is 
following civilization's precept that life 
comes first. In the operating room, the 
surgeon may find exhaustion or terror, 
but he does not find moral ambiguity. 

The surgeon pits his training and 
determination against the vagaries of 
disease and human vulnerability The 
skills he has learned from that first sur- 
gical knot onward are brought together 
to solve the three-dimensional puzzle 
that is the operative field. At the end of 
a successful operation, he feels exulta 
tion — and the world outside pales. 

It was this less colorful world that I 
entered that final Monday as I left my 
office. One week later, as I started the 
second part of the knot on my shoelace, 
I realized I would never again tie a knot 
on whose integrity a life and my reputa 
tion would depend. Startled, I felt a sud- 
den kinship with those whose lives have 
been punctuated by moments of intensi- 
ty: the actor who suffers years of priva- 
tion to strut his stuff on the stage only 
briefly, the athlete for whom game time 
is the only time, the warrior whose merit 
is defined by his battles. My hand shook 
and the previously tightened knot 
became loose. I untied the knot and 
started again. ■ 

Ken Kenigshcrg '55 retired in 2001 from his 
pediatric surgical practice at North Shore 
University Hospital in Manhassct, New York, 
where he now conducts research on sepsis. 



AUTUMN 2004 • HARVARD MEDICAL ALUMNI BULLETIN 



51 



ALUMNA PROFTT.F, 



YVETTE ROUBIDEAUX '89 



Promises to Keep 



MAGINE YOU ARE THE ONLY DOCTOR IN A RURAL HOSPITAL ONE 

Sunday morning. Though you've barely finished your 
internal medicine residency, here you are, covering the ER. 
Suddenly the EMS radio squawks, and a voice barks the details: 
a pickup truck has hurtled over a cliff. Ten kids, three adults. 




Two dead. Ambulances are already racing 
your way. You dorft have time to picture 
the children being catapulted from the 
truck bed to the rocks and dust of reser- 
vation earth, their skulls fractured, their 
limbs contorted. You make quick calcula- 
tions: eleven patients, one nurse, one 
physician. You are several beds short, sev- 
eral heart monitors short, and two hours 
from a trauma center. It's time to act. 

When Yvette Roubideaux '89 received 
that call at the San Carlos Indian Hospi 
tal in Arizona, she mobilized the rein- 
forcements. "I called in four doctors who 
lived nearby," she says. "They helped sta- 
bilize the victims while I arranged for 
helicopters and ambulances to transfer 
the patients to other facilities." She was 
frustrated that the patients' urgent care 
was so delayed. 

"Working at the reservation hospital 
was like doing another residency," 
Roubideaux says. "We had to practice 
beyond our training. The only way I 
could justify covering the ER was by 
telling myself that if I wasn't there, then 
no one might be." 

Such episodes clarified for Roubideaux 
the degree of disparity between the care 
available to Native Americans and that 
available to most Americans. They also 
helped shape the evolution of her career 
from clinical physician to public health 
advocate and researcher. "I helped indi- 
viduals at San Carlos," she says, "but I 
couldn't address the larger need." 

Growing up in Rapid City South 
Dakota, in the 1970s, Roubideaux, a Rose- 
bud Sioux, often heard relatives complain 
about the quality of care they received 
from the Indian Health Service. "Every 
time they went to the clinic they would 



see a different doctor," she says. "My non 
Indian friends had the same pediatricians 
their entire childhoods; I never saw the 
same doctor twice." And she never saw a 
single Native American physician. 

Roubideaux has spent the last ten 
years trying to remedy that lack and 
other inequalities in Native American 
health care. Named the 2004 Indian 
Physician of the Year by the Association 
of American Indian Physicians, she has 
helped drive health policy, research, and 
funding aimed at slashing the rate of 
diabetes among all Native Ameri 
cans. She co-edited the first book 
on Native American health policy. 
And she recruits Native American 
students into the health profes- 
sions, serving as a role model in a 
field where still there are few. 

Roubideaux has seen the differ 
ence her efforts make, even while 
she was that young doctor in a 
reservation hospital. She saw 
patients' faces light up when they 
realized that she — a Native Ameri 
can — was their doctor. One elderly 
woman grasped her hand at the end 
of the appointment and beamed as 
she told Roubideaux, "I'm so glad 
you are here for our people." 

During the four years she prac 
ticed internal medicine with the 
Indian Health Service in the 
mid-1990s, nearly every patient 
Roubideaux saw had diabetes. 
"One day in the clinic I scolded a 
nurse for not getting a fingerstick 
glucose on a patient in her twerj 
ties. When the nurse told me the 
patient wasn't diabetic, I was star- 
tled to realize I had come to expect 



all my patients to have diabetes, even 
when they were young." 

On the Gila River Reservation in Ari 
zona, where Roubideaux practiced for a 
year, diabetes afflicts 80 to 90 percent of 
all adults, and children as young as five 
are often diagnosed with it. "Many 
patients were fatalistic and didn't believe 
that controlling their blood glucose 
would make a difference," she says. With 
education, came progress. 

But again, the need was greater than 
Roubideaux could address in one clinic. 
So she earned a degree from the Harvard 
School of Public Health and embarked 
on research with the Indian Health Ser- 
vice's diabetes program, which had an 
abundance of data from 20 years of mon- 
itoring the disease. She quickly realized 
that data equaled funding. In 1997, while 
she was still a public health student. 




WARM PRAISE: Yvette Roubideaux received a 
traditional blanket as part of the celebration 
naming her Indian Physician of the Year. 



52 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 




When the nurse told me the patient wasn't diabetic, 
I was startled to realize I had come to expect all my 
patients to have diabetes, even when they were young." 



Congress passed legislation to give the 
Indian Health Service $30 million a year 
for diabetes prevention and treatment 
programs. Roubideaux's research and 
advocacy, including testifying before 
Congress, have since helped that figure 
climb to $150 million a year, fueling 300 
new programs and a dramatic improve 
ment in the quality of diabetes care. 

Roubideaux championed the National 
Diabetes Education Program's Move It! 
campaign, which allocates money to 
Bureau of Indian Affairs schools for 
exercise programs and equipment. One 
school used the boon to buy more uni- 
forms, because one team had been wear- 
ing the old uniforms in the morning and 
another had been donning the same 
ones — unwashed — in the afternoon. 



On the University of Arizona campus 
where she teaches, Roubideaux encour- 
ages Native American students to learn 
about and participate in research pro- 
jects. "Research has a bad reputation in 
Indian communities," she says. "In the 
past, investigators have often come into 
Indian communities, collected their data, 
and then left without telling the tribe 
about their results or any potential bene- 
fits to the community." 

Many tribes now exert their sovereign 
status by banning scientific inquiry in 
their communities unless investigators 
obtain their approval and can demon- 
strate that they will conduct their 
research with respect. 

"Yet, to strengthen the case for better 
policy initiatives," Roubideaux says, "we 



need more data on Indian health." She has 
educated both investigators and tribes on 
culturally sensitive research methods. 

Roubideaux has recently shifted her 
attention to correcting imbalances in care 
within overlooked Native American 
subgroups, such as the elderly and 
urban populations. For Native Americans 
in urban areas, health care is sometimes 
worse than tor the uninsured, Roubideaux 
says. Many have moved to cities to pursue 
employment and education, which can 
Leave them without access to health care, 
since most urban areas lack Indian Health 
Service climes. And many Native Ameri- 
cans are ineligible for Medicare, because 
it they've lived on a reservation, they've 
never paid into Social Security. 

Roubideaux addresses such health 
care policy issues in her 2001 book, 
Promises to Keep: Public Health Policy for 
American Indians and Alaska Natives in 
the 21st Century. The title highlights 
Roubideaux's belief that the federal gov- 
ernment has tailed to honor its obligation 
to provide for the health and welfare of 
Native Americans in exchange for their 
lands. Proof, Roubideaux says, is that cur- 
rent funding for Indian health care meets 
only 40 percent of need. 

In response to this dearth, many tribes 
have taken over managing health care 
programs themselves. "This is a huge 
trend," Roubideaux says. "We intended 
the book to be used by tribes as a refer- 
ence when changing over to their own 
health programs." 

Never cowed by statistics that might 
paralyze someone else, Roubideaux applies 
pressure and passion to improve Native 
American health care. She still employs 
the lesson learned from the crisis in the 
San Carlos emergency room and its 
eleven-to-one odds: call in the reinforce- 
ments. This time she's ensuring that 
more Native American physicians can be 
there for their people. ■ 

Janice' O'Lcary is assistant editor of the 
Harvard Medical Alumni Bulletin. 



AUTUMN 2004 • HARVARD MEDICAL ALUMNI BULLETIN 



S3 



CLASS NOTES 



NEWS ABOUT ALUMNI 



Henry Work 



1 937 "Fie on the Bulletin for start- 
ing the Class Notes at 1942 
in the summer issue! Those 
of us in the thirties and 
before are not necessarily 
dead! In fact, as we approach 
our listing in the obituary 
section we become ever 
more proud of our years. 
Please restore us; the Class 
of '37 still has some solid 
members. On a nicer note, it 
is good to have a lectureship 
named for my former student 
at UCLA, Alvin Poussaint. 
May it do well." 

Samuel Potsubay 



1 940 "I'm still enjoying my half- 
mile backstroke swim three 
times a week, but now I 
must have rest periods. 
Tempusfugit!" 

Bernard Ryan 

"I retired to a horse farm on 
Shelter Island in New York in 
1986. 1 still cut wood and 
drive a tractor. Betty remains 
active. I recently spoke with 
Shelton Reed. My regards to 
all the '40-ers." 

John Sholl III 



I 94 1 "I'm still teaching second-year 
medical students from St. 
Matthew's University how to 
do a proper history and physi- 
cal exam." 

Albert Ferguson, Jr. 

'43B received the third annual 

American Orthopaedic Asso- 
ciation-Zimmer Award for 
Distinguished Contributions 
to Orthopaedics. The annual 
honor recognizes leaders in 
the field and rewards them 
with a $50,000 grant. Fergu- 
son was chairman of the 
Department of Orthopaedic 
Surgery and the David Silver 



Professor of Orthopaedics at 
the University of Pittsburgh 
School of Medicine from 1952 
until his retirement in 1986. 
"Receiving this award was a 
wonderful surprise," he says. 

Charles "Dav" Cook 



1 944 "I retired from teaching in 
2000 and continue to spend 
three months on an island in 
Passamaquoddy Bay, Canada. 
I'm beginning to experience 
'modern,' impersonal, test- 
oriented medicine, and I don't 
like it!" 



David Solomon 



1 946 "Ronnie and I now have two 
great-granddaughters, and 
we're loving them. We feel 
pretty young ourselves, and I 
still do a little work." 

Ronald Germain 

1 947 "My longtime friend Paul 
Hoeprich died in September. 
It seems like yesterday that 

I was best man at his wed- 
ding. Though death has 
taken him away, memories 
death cannot take." 

Hermes Grillo 

"I have written a short 
account, which appears 
in the November 2004 
issue of Surgery, of Edward 
Churchill's [Class of 1920] 




conception and establishment 
of the rectangular surgical 
residency. This signified a 
major transformation in 
surgical education." 

William Waring 
received the 2004 Edwin L. 
Kendig, Jr. Award from the 
American Academy of Pedi- 
atrics. The award recognizes 
outstanding achievement 
in pediatric pulmonology. 

Kenneth Walker 



1 950 "I celebrated my 80th birth- 
day this year, but I'm still 
practicing office gynecology 
and writing my syndicated 
newspaper medical column, 
published by 67 Canadian 
newspapers — a great learning 
experience!" 

Clement Hiebert 

1951 "With heavy hearts we left 
our lovely lakeside home for a 
very nice townhouse on the 
Royal River in Yarmouth, 
Maine. We're settling in and 
look forward to friends visit- 
ing just as usual." 

Kathleen Mogul 



1952 "I'm mostly retired, except for 
a little teaching. I miss prac- 
ticing, but enjoy visiting our 
children and five grandchil- 
dren and going to museums, 
concerts, and the theater. 
Health and body maintenance 
becomes ever more time con- 
suming, alas." 

S. Louis Mogul 
"I'm more patient than doc- 
tor now, and I look back 
fondly to when it was the 
other way around. I do value 
the psychiatric teaching I 
still do and especially study- 
ing music. Most fulfilling, 
though, is my family." 



54 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2004 




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